The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis

Performance characteristics and complications of an Inter-Changeable Operator Model for intubation in an Australian helicopter emergency medical service

OBJECTIVE

The Inter-Changeable Operator Model (ICOM) enables paramedics and flight nurses to perform intubations interchangeably with team physicians in prehospital critical care. However, literature on ICOM characteristics and performance is limited.

METHODS

We conducted a retrospective, observational study of an ICOM operating within an Australian Helicopter Emergency Medical Service over a nine-year period. First pass success, major complication rates and clinically important time intervals were compared between first intubator groups.

RESULTS

A total of 413 patients met the inclusion criteria, with paramedics performing the majority of first intubation attempts (379/413, 91.8%). Physicians primarily conducted second intubation attempts and managed high-risk patients. In unadjusted analysis, the risk of major complication in the paramedic/supervised registrar group was not lower than the most senior physician intubator group (relative risk [RR] 0.59, 95% confidence interval [CI]: 0.26-1.32; P = 0.198) and after adjustment the risk was also not lower (RR 0.60, 95% CI: 0.24-1.54; P = 0.289). First pass failure occurred in 12 (3.1%) and 1 (4.8%) patients intubated by paramedic/supervised registrar and most senior physician groups, respectively (P = 0.498). The median (95% CI) adjusted difference in contact to intubation time between paramedic/supervised registrar first intubator and most senior physician groups was -2 min (-7 to 3; P = 0.392). Total adjusted scene time was also not significantly different between groups (median difference 2 min, 95% CI: -3 to 7; P = 0.500).

CONCLUSIONS

Paramedics conducting most intubations within an ICOM are both safe and efficient. Larger studies are required to examine differences between physician subgroups.

Use of portable air cleaners within an ambulance workspace

Emergency medical service (EMS) providers face significant exposure to infectious aerosols during outbreaks like the COVID-19 pandemic. Most ambulances lack ventilation controls to reduce EMS worker exposure to these aerosols. Ambulances are smaller than hospital rooms and handle numerous patients daily, increasing contact with potentially infectious individuals. Ventilation controls such as portable high-efficiency particulate air (HEPA) filtration can mitigate this risk. Few studies have assessed portable HEPA filters in ambulances. This study evaluated two HEPA filter models in an unoccupied, stationary research ambulance at the National Institute for Occupational Safety and Health (NIOSH) in Cincinnati. A tracer aerosol simulated patient aerosol generation, and optical particle counters (OPCs) measured aerosols. The HEPA units were tested individually, placed in the same location, and operated for 50 min. Results showed significant reductions in aerosol concentrations during the generation phase, with performance varying during the decay period. Overall, HEPA units reduced particle concentrations by around 50% during the generation phase and continued to be effective through the decay period. This demonstrates the potential of portable HEPA filters as an affordable and effective option for air cleaning in ambulance patient modules.

Maintenance of prehospital anaesthesia in trauma patients: inconsistencies and variability in practice

Background

Literature on prehospital anaesthesia predominantly focuses on preparation and induction, while there is limited guidance on anaesthesia maintenance. The hypothesis of this study was that for prehospital trauma patients, protocols and practice for anaesthesia maintenance may vary considerably between services. Hence, we sought to describe the practice of prehospital anaesthesia maintenance for trauma patients in Australia, New Zealand, and the UK.

Methods

An online practice survey of prehospital and retrieval services in Australia, New Zealand, and the UK was conducted from May to September 2022. Branching logic of between five and 140 questions covered services' background information, protocols relating to anaesthesia maintenance, and perceived effectiveness and governance.

Results

Forty-two services were approached with an 81% response rate. While most services (88%) had some form of maintenance protocol, only 14% had one specific for trauma patients. Most services (61%) used a combination of intermittent boluses and continuous infusions. Ketamine and midazolam were the favoured hypnotics, and fentanyl the favoured opioid. However, there was considerable variation in drug selection and dosing, and in the detail contained within protocols. There was high self-reported confidence in effectiveness and governance of anaesthesia maintenance practices.

Conclusions

Protocols for anaesthesia maintenance in prehospital trauma patients show considerable variation in content and detail across the surveyed services. Further consideration of pharmacokinetics and the specific aims of anaesthesia maintenance is warranted. More research is needed to establish the optimal choice of drugs, dosing, delivery, and adjustment criteria for anaesthesia maintenance in prehospital trauma patients.

Down the Wrong Pipe: Tension Pneumoperitoneum from Esophageal Intubation

BACKGROUND

Tension pneumoperitoneum (TPP) is a rare but life-threatening pathology in which significant accumulation of free air in the peritoneum pressurizes the abdominal cavity, creating conditions similar to abdominal compartment syndrome. Due to compression of intra-abdominal vasculature, TPP results in hemodynamic instability. While it most commonly occurs due to viscus perforation in the setting of recent endoscopy, gastric perforation from resuscitative efforts can also lead to TPP.

CASE REPORT

We present a case of a 58-year-old female who was intubated out-of-hospital for unresponsiveness, then subsequently developed abdominal distension, mottled lower extremities, and hemodynamic instability. In the emergency department, the patient self-extubated for a brief time before suffering cardiac arrest. During resuscitative efforts, imaging showed significant abdominal free air concerning for tension pneumoperitoneum. The likely etiology was positive pressure ventilation after esophageal intubation, resulting in gastric perforation and rapid accumulation of air in the peritoneal cavity. Despite emergent abdominal needle decompression and prompt exploratory surgery, the patient expired. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TPP is a critical pathology that should be on the differential for any patient with recent unverified intubation presenting with hemodynamic instability and abdominal distension. Abdominal needle decompression is a key intervention for the patient with TPP and should be in the emergency physician's skillset. It is also a reminder that intubated patients require confirmation of correct endotracheal tube placement to prevent negative outcomes.

Benefits of targeted deployment of physician-led interprofessional pre-hospital teams on the care of critically Ill and injured patients: a systematic review and meta-analysis

INTRODUCTION

Over the past three decades, more advanced pre-hospital systems have increasingly integrated physicians into targeted roles, forming interprofessional teams. These teams focus on providing early senior decision-making and advanced interventions while also ensuring rapid transport to hospitals based on individual patient needs. This paper aims to evaluate the benefits of an inter-professional care model compared to a model where care is delivered solely by paramedics.

METHODOLOGY

A meta-analysis and systematic review were conducted using the guidelines of PRISMA 2020. Articles were identified through a systematic search of three databases and snowballing references. A systematic review was conducted of articles that met the inclusion criteria, and a suitable subset was included in a meta-analysis. The survival and mortality outcomes from the studies were then pooled using the statistical software Review Manager (RevMan) Version 8.2.0.

RESULTS

Two thousand two hundred ninety-six articles were found from the online databases and 86 from other sources. However, only 23 articles met the inclusion criteria of our study. A pooled analysis of the outcomes reported in these studies indicated that the mortality risk was significantly reduced in patients who received pre-hospital care from interprofessional teams led by physicians compared with those who received care from paramedics alone (AOR 0.80; 95% CI [0.68, 0.91] p = 0.001). The survival rate of critically ill or injured patients who received pre-hospital care from interprofessional teams led by physicians was increased compared to those who received care from paramedics alone (AOR 1.49; 95% CI [1.31, 1.69] P < 0.00001).

CONCLUSIONS

The results of our analysis indicate that the targeted deployment of interprofessional teams led by physicians in the pre-hospital care of critically ill or injured patients improves patient outcomes.

Comparing Air Medical Personnel Intubation Success Rates Using Direct, Channeled Video-Assisted, and Unchanneled Video-Assisted Laryngoscopy

OBJECTIVE

The aim of this study was to determine the first-pass intubation success rates of air medical providers using direct laryngoscopy, channeled blade video laryngoscopy, and nonchanneled blade video laryngoscopy.

METHODS

This was a retrospective cohort study of the Orlando Health Air Care Team (ACT) airway quality registry over a 5-year period. The ACT had 3 approved approaches for endotracheal intubation: direct laryngoscopy, the King Vision (Ambu, Ballerup Denmark) channeled blade laryngoscope, or the C-MAC (Karl-Storz, Tuttlingen Germany) (nonchanneled) laryngoscope. The main outcome was the first-pass success rate. The secondary outcomes included the number of attempts, the overall success rate, and complications.

RESULTS

Of 517 intubations, 312 were performed with direct laryngoscopy, 126 with a channeled video laryngoscope, and 79 with a nonchanneled laryngoscope. The mean number of attempts was 1.26, and the overall success rate was 93%. Use of the nonchanneled video laryngoscope had a higher first-pass success rate than direct or channeled laryngoscopy (92% vs. 76% and 78%, P = .006), required fewer attempts (1.09 [95% confidence interval (CI), 1.01-1.17] vs. 1.29 [95% CI, 1.23-1.35] and 1.28 [95% CI, 1.18-1.38], P < .001), and a higher overall success rate for intubation (99% vs. 90% and 95%, P = .018).

CONCLUSION

The use of a nonchanneled video laryngoscope provided higher first-pass success rates, fewer total attempts, and higher overall success rates.

Bougie approach improves first-attempt success rate compared to stylet approach in patients with difficult airway needing endotracheal intubation: a meta-analysis

INTRODUCTION

Bougies and stylets are widely acknowledged as effective tools for managing endotracheal intubation, uncertainties persist regarding the comparative efficacy and safety of bougie versus stylet approaches in endotracheal intubation.

EVIDENCE ACQUISITION

A comprehensive electronic search was conducted on the Cochrane Library, PubMed, and Embase databases from inception to December 9, 2023, using the keywords "endotracheal intubation," "bougie," and "stylet." This meta-analysis aims to evaluate and compare the performance of bougies and stylets in patients undergoing endotracheal intubation.

EVIDENCE SYNTHESIS

A total of 12 articles, encompassing 2534 participants, were included in this meta-analysis. The bougie approach did not exhibit superiority in first-attempt success rate (83.6% vs. 81.7%; OR, 1.06, 95% CI, 0.49 to 2.29; P=0.89) and total intubation success rate (99.3% vs. 97.6%; OR, 2.32, 95% CI, 0.44 to 12.34; P=0.32, I2>50%, P<0.001). However, in patients with difficult airways, the bougie approach demonstrated a superior first-attempt success rate compared to the stylet approach (93.8% vs. 76.4%; OR, 5.25, 95% CI, 2.74 to 10.05; P<0.001). There was no significant difference in complications between the bougie and stylet approaches (P>0.05).

CONCLUSIONS

For patients with difficult airway characteristics, our recommendation is to perform endotracheal intubation (ETI) using the bougie approach over the stylet approach, as it has been associated with a better first-attempt success rate. Notably, the advantages of using a bougie may be less pronounced for patients without signs of a difficult airway.

Comparative study of the McGrath™ videolaryngoscope blades and conventional laryngoscopy efficacy during mechanical chest compressions: Insights from a randomized trial with 90 anesthesiologists on objective and subjective parameters

AIMS

This study aimed to compare the efficacy and utility of the McGrath™ videolaryngoscope, using the Macintosh-like McGrath™ MAC blade and the hyperangulated McGrath™ MAC Xblade with a conventional Macintosh blade under simulated resuscitation conditions.

METHODS

A prospective, randomized study under conditions mimicking ongoing chest compressions was conducted with 90 anesthesiologists. Intubation success rates, time-to-vocal cords, time-to-intubate, and time-to-ventilate were measured. Additionally, the study assessed the subjective ratings and the perceived workload using the 'NASA-task-load-index' during the procedure.

RESULTS

The overall intubation success rate was device dependent 99-100%. The McGrath™ MAC and McGrath™ MAC Xblade showed faster visualization times compared to conventional blades. The MAC blade demonstrated superior performance in time-to-intubate and time-to-ventilate compared to both conventional and MAC Xblades. Despite excellent visualization, the MAC Xblade posed challenges in tube placement, reflected in a prolonged intubation time of >120 seconds in one case. Both MAC and MAC Xblade reduced potential dental injuries and interruptions to chest compressions compared to conventional laryngoscopes. User experience significantly impacted intubation times with conventional laryngoscopes, but this effect was mitigated with videolaryngoscopy. Participants reported lower stress and effort when using videolaryngoscopes, with the MAC blade rated superior in perceived time pressure.

CONCLUSION

The study supports the superiority of videolaryngoscopy with a Macintosh-like blade over conventional laryngoscopy during mechanical chest compressions, particularly for less experienced users. The McGrath™ MAC blade, in particular, offers advantages in intubation time, user-friendliness, and reduced stress. However, the MAC Xblade's challenges during tube placement highlight the need for further clinical validation. Continued research is essential to refine guidelines and improve resuscitation outcomes.

Quality and safety in prehospital airway management - retrospective analysis of 18,000 cases from an air rescue database in Germany

BACKGROUND

Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective.

METHODS

This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0.

RESULTS

Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11).

CONCLUSIONS

Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety.

TRIAL REGISTRATION

The study was registered in the German Register for Clinical Studies (number DRKS00028068).

Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success

STUDY OBJECTIVE

Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database.

METHODS

We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders.

RESULTS

We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes.

CONCLUSION

Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success.

Transitions in Video Laryngoscope Technology to Improve First-Pass Success

Prehospital intubation is a high-risk, relatively low frequency procedure. Provider experience plays a key role in first-pass success rates, especially in the setting of a difficult airway. While strong foundational knowledge is necessary to equip providers with an adequate understanding of intubation procedures and the skill set needed to manage a difficult airway, effective equipment may provide an extra boost in first-pass success for novice airway providers. First-pass success is correlated with decreased adverse events and should be maximized in the prehospital setting. After evaluating overall first-pass success of 66% to 83% from 2016 to 2020, AHN LifeFlight enacted changes in education, training, and video laryngoscopy equipment to successfully increase first-pass success to over 90%.

Care needs of adults with spinal trauma in the prehospital and hospital setting from the perspective of patient care team: A qualitative research

BACKGROUND

Appropriate care of patients with definite spinal cord injury or at risk of it in the prehospital and hospital stages requires comprehensive planning in the health system. It is also the requirement of any successful program to explain the needs from the perspective of its stakeholders. Thus, this study aimed to discover the care needs of adults with spinal trauma in prehospital and hospital settings from the perspective of the patient care team.

MATERIALS AND METHODS

This qualitative study was conducted with the participation of urban and rural prehospital emergency personnel and emergency departments of educational and therapeutic hospitals affiliated to Isfahan, Tehran, Shiraz, Kermanshah, Ahvaz, and Yasuj Universities of Medical Sciences, through conducting 36 in-depth semi-structured interviews from September to December 2021. Using purposive sampling method, the participants were selected considering the maximum variation. The data saturation was reached after conducting interviews and group discussions with 36 subjects. Data were analyzed using conventional content analysis approach. Lundman and Graneheim approach were used for the study rigour. Data were simultaneously analyzed using MAXQDA software version 10.

RESULT

During the data analysis, two themes of prehospital care with two main categories (emergency care and management of secondary complications of spinal trauma) and hospital care with two main categories (emergency care and management of secondary complications of spinal trauma) emerged.

CONCLUSION

Emergency care and management of secondary complications of spinal cord injury in the prehospital and hospital stages can affect treatment results, improve quality of life, and reduce mortality rate, secondary injuries, and healthcare costs. Thus, identification of the care needs of the adults with spinal trauma from the perspective of the patient care team can help the authorities to plan appropriate interventions.

Point-of-care ultrasound for airway management in the emergency and critical care setting

Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, point-of-care ultrasound has been increasingly utilized for this application. Several measures can be used to sonographically predict a difficult airway, including skin to epiglottis, hyomental distance, and tongue thickness. Ultrasound can also be used to confirm endotracheal tube intubation and assess endotracheal tube depth. Ultrasound is superior to the landmark-based approach for locating the cricothyroid membrane, particularly in patients with difficult anatomy. Finally, we provide an algorithm for using ultrasound to manage the crashing patient on mechanical ventilation. After reading this article, readers will have an enhanced understanding of the role of ultrasound in airway management.

Cardiorespiratory consequences of attenuated fentanyl and augmented rocuronium dosing during protocolised prehospital emergency anaesthesia at a regional air ambulance service: a retrospective study

BACKGROUND

Pre-Hospital Emergency Anaesthesia (PHEA) has undergone significant developments since its inception. However, optimal drug dosing remains a challenge for both medical and trauma patients. Many prehospital teams have adopted a drug regimen of 3 mcg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium ('3:2:1'). At Essex and Herts Air Ambulance Trust (EHAAT) a new standard dosing regimen was introduced in August 2021: 1 mcg/kg fentanyl, 2 mg/kg ketamine and 2 mg/kg rocuronium (up to a maximum dose of 150 mg) ('1:2:2'). The aim of this study was to evaluate the cardiorespiratory consequences of a new attenuated fentanyl and augmented rocuronium dosing regimen.

METHODS

A retrospective study was conducted at EHAAT as a service evaluation. Anonymized records were reviewed from an electronic database to compare the original ('3:2:1') drug dosing regimen (December 2019-July 2021) and the new ('1:2:2') dosing regimen (September 2021-May 2023). The primary outcome was the incidence of absolute hypotension within ten minutes of induction. Secondary outcomes included immediate hypertension, immediate hypoxia and first pass success (FPS) rates.

RESULTS

Following exclusions (n = 121), 720 PHEA cases were analysed (360 new vs. 360 original, no statistically significant difference in demographics). There was no difference in the rate of absolute hypotension (24.4% '1:2:2' v 23.8% '3:2:1', p = 0.93). In trauma patients, there was an increased first pass success (FPS) rate with the new regimen (95.1% v 86.5%, p = 0.01) and a reduced incidence of immediate hypoxia (7.9% v 14.8%, p = 0.05). There was no increase in immediate hypertensive episodes (22.7% vs. 24.2%, p = 0.73). No safety concerns were identified.

CONCLUSION

An attenuated fentanyl and augmented rocuronium dosing regimen showed no difference in absolute hypotensive episodes in a mixed cohort of medical and trauma patients. In trauma patients, the new regimen was associated with an increased FPS rate and reduced episodes of immediate hypoxia. Further research is required to understand the impact of such drug dosing in the most critically ill and injured subpopulation.

Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting

OBJECTIVE

Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades.

METHODS

We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events.

RESULTS

Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64-1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20-36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases.

CONCLUSIONS

Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.

Association between prehospital physician clinical experience and discharge at scene - retrospective cohort study

BACKGROUND

Clinical experience has been shown to affect many patient-related outcomes but its impact in the prehospital setting has been little studied.

OBJECTIVES

To determine whether rates of discharge at scene, handover to paramedics and supervision are associated with clinical experience.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective study, performed on all prehospital interventions carried out by physicians working in a mobile medical unit ("service mobile d'urgence et de réanimationˮ [SMUR]) at Geneva University Hospitals between 1 January 2010 and 31 December 2019. The main exclusion criteria were phone consultations and major incidents with multiple casualties.

EXPOSURE

The exposure was the clinical experience of the prehospital physician at the time of the intervention, in number of years since graduation.

OUTCOME MEASURES AND ANALYSIS

The main outcome was the rate of discharge at scene. Secondary outcomes were the rate of handover to paramedics and the need for senior supervision. Outcomes were tabulated and multilevel logistic regression was performed to take into account the cluster effect of physicians.

RESULTS

In total, 48,368 adult patients were included in the analysis. The interventions were performed by 219 different physicians, most of whom were male (53.9%) and had graduated in Switzerland (82.7%). At the time of intervention, mean (standard deviation [SD]) level of experience was 5.2 (3.3) years and the median was 4.6 (interquartile range [IQR]: 3.4-6.0). The overall discharge at scene rate was 7.8% with no association between clinical experience and discharge at scene rate. Greater experience was associated with a higher rate of handover to paramedics (adjusted odds ratio [aOR]: 1.17, 95% confidence interval [CI]: 1.13-1.21) and less supervision (aOR: 0.85, 95% CI: 0.82-0.88).

CONCLUSION

In this retrospective study, there was no association between level of experience and overall rate of discharge at scene. However, greater clinical experience was associated with higher rates of handover to paramedics and less supervision.

Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study

BACKGROUND

Prehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter.

METHODS

This observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetist-staffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations.

RESULTS

Of the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval -2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit Δ=-4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004).

CONCLUSIONS

Both in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort.

CLINICAL TRIAL REGISTRATION

NCT04206566.

Comparing Intubation Success Between Flight Nurses and Flight Paramedics in Helicopter Emergency Medical Services

OBJECTIVE

Intubation is a vital skill performed by flight nurses and paramedics. Before flight training, nurses do not routinely intubate and must be trained in proper techniques. Flight paramedics universally train in intubation before flight training and are the primary managers of in-flight airways. The aim of this study was to determine if a difference exists in intubation attempts and success rates between flight nurses and flight paramedics.

METHODS

A 5-year retrospective chart review was performed from a regional helicopter emergency medical service. Intubation attempts and the success of flight nurses compared with flight paramedics were the primary outcomes.

RESULTS

Three hundred three of 322 cases in which intubation was attempted were successful. Three hundred forty-four total intubation attempts were made. Two hundred seventy-one (88.9%) patients were intubated by paramedics, and 32 (10.5%) were intubated by nurses. Of the 19 unsuccessfully intubated patients, 14 (73.7%) were attempted by a paramedic and 5 (26.3%) by a nurse. Two hundred seventy-seven intubations were successful on the first attempt, 250 (90.3%) of which were performed by a paramedic and 27 (9.7%) by a nurse.

CONCLUSION

Flight paramedics performed more intubations with greater success than flight nurses.

Clinical Research in Prehospital Care: Current and Future Challenges

Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.

Effect of prehospital intubation on mortality rates in patients with traumatic brain injury: A systematic review and meta-analysis

OBJECTIVE

It is unclear if prehospital intubation improves survival in patients with traumatic brain injury. We performed a systematic review and meta-analysis to assess the impact of prehospital intubation on mortality rates of traumatic brain injury.

METHODS

PubMed, CENTRAL, Web of Science, and Embase databases were searched without any language restriction up to 20 June 2022 for all types of comparative studies reporting survival of traumatic brain injury patients based on prehospital intubation.

RESULTS

In total, 18 studies with 41,185 patients were eligible for inclusion. Meta-analysis showed that traumatic brain injury patients receiving prehospital intubation had higher odds of mortality as compared to those not receiving prehospital intubation. Meta-analysis of adjusted data also indicated that prehospital intubation was associated with increased odds of mortality in traumatic brain injury patients. The results did not change on sensitivity analysis. Subgroup analysis based on study type, the severity of traumatic brain injury, inclusion of isolated traumatic brain injury, emergency department intubation in the control group, and prehospital intubation group sample size demonstrated variable results.

CONCLUSION

Heterogeneous data from mostly observational studies demonstrates higher mortality rates among traumatic brain injury patients receiving prehospital intubation. The efficacy of prehospital intubation is difficult to judge without taking into account multiple confounding factors.

Physician-staffed prehospital units: a retrospective follow-up from an urban area in Scandinavia

BACKGROUND

The aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved.

METHODS

This retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night - from January 1, 2021 to December 31, 2021.

RESULTS

In 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%).

CONCLUSION

The study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.

Rapid Sequence Intubation Using the SEADUC Manual Suction Unit in a Contaminated Airway

The case presented here highlights the utility/feasibility of the SEADUC (EM Innovations, Galloway, OH) manual suction unit in clearing a contaminated airway during rapid sequence intubation. The case also highlights the importance of intubation in a patient with declining mental status in the prehospital environment. A 75-year-old woman suffered a head injury, and a helicopter emergency medical service team staffed with a physician and nurse was tasked with retrieval and transfer back to the tertiary care center. As the flight team rendezvoused with ground emergency medical services and the patient, a decision to intubate was made because of the patient's declining mental status and inability to protect her own airway. While in preparation for intubation, it was noted that the ambulance's electrical suction system was not working, and the flight crew had to resort to a SEADUC manual suction unit to clear the patient's airway of contaminants. The patient's airway was cleared, and she was successfully intubated and transported to a tertiary care center where the patient underwent an emergent neurosurgery procedure/decompression and was discharged home a few weeks later.

Maintenance and Development of Paramedics' Competence on Joint Emergency Medical Service and Helicopter Emergency Medical Service Missions

OBJECTIVE

In health care, learning and collaboration between professions are crucial in providing patient-centered, responsive, and high-quality care. Given that interprofessional learning can occur indirectly while working but is scarcely studied in the context of prehospital emergency care, we examined the maintenance and development of paramedic competence on joint emergency medical service (EMS) and helicopter emergency medical service (HEMS) missions.

METHODS

Qualitative methodology was chosen. Sixty-one Finnish paramedics and EMS field supervisors answered a single open-ended survey question. Inductive content analysis was used to analyze the data.

RESULTS

The maintenance and development of paramedics' competence on joint EMS and HEMS missions formed 2 main categories: the transfer of professional skills and interactive competence development. The transfer of skills was formed by 3 upper categories: practicing working as part of the team, transmission of tacit knowledge, and deepening of clinical knowledge. Interactive competence development was formed by 2 upper categories: ensuring one's own competence and educational working model as built-in. All the upper categories had several subcategories.

CONCLUSION

EMS and HEMS joint missions provide an additional learning opportunity for paramedics. The expertise, examples, and educational attitudes shared by the HEMS are valued. The results reveal the need for further research on this subject.

Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate

OBJECTIVE

The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic.

METHODS

We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization.

RESULTS

We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73-3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58-2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001).

CONCLUSIONS

VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.

The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine

BACKGROUND

Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl.

OBJECTIVES

To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use.

METHODS

A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction.

RESULTS

Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21).

CONCLUSIONS

The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.

Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis

BACKGROUND

Front-of-neck access (FONA) is an emergency procedure used as a last resort to achieve a patent airway in the prehospital environment. In this systematic review with meta-analysis, we aimed to evaluate the number and success rate of FONA procedures in the prehospital setting, including changes since 2017, when a surgical technique was outlined as the first-line prehospital method.

METHODS

A systematic literature search (PROSPERO CRD42022348975) was performed from inception of databases to July 2022 to identify studies in patients of any age undergoing prehospital FONA, followed by data extraction. Meta-analysis was used to derive pooled success rates. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From 909 studies, 69 studies were included (33 low quality; 36 very low quality) with 3292 prehospital FONA attempts described (1229 available for analysis). The crude median success rate increased from 99.2% before 2017 to 100.0% after 2017. Meta-analysis revealed a pooled overall FONA success rate of 88.0% (95% confidence interval [CI], 85.0-91.0%). Surgical techniques had the highest success rate at a median of 100.0% (pooled rate=92.0%; 95% CI, 88.0-95.0%) vs 50.0% for needle techniques (pooled rate=52.0%; 95% CI, 28.0-76.0%).

CONCLUSIONS

Despite being a relatively rare procedure in the prehospital setting, the success rate for FONA is high. A surgical technique for FONA appears more successful than needle techniques, and supports existing UK prehospital guidelines.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022348975.

Factors associated with tracheal intubation-related complications in the prehospital setting: a prospective multicentric cohort study

Background Emergency tracheal intubation is routinely performed in the prehospital setting. Airway management in the prehospital setting has substantial challenges. Objective The aim of the present study was to determine risk factors predicting tracheal intubation-related complications on the prehospital field. Setting A prospective, multicentric, cohort study which was conducted in three mobile ICUs (MICUs; service mobile d'urgence et de réanimation).Outcome measures and analysis Tracheal intubation-related complications were defined as the occurrence of at least one of the following events: oxygen desaturation (SpO2 < 90%) during tracheal intubation, aspiration (regurgitation visualized during laryngoscopy), and vomiting. Difficult intubation was defined as more than two failed direct laryngoscopic attempts, or the need for any alternative tracheal intubation method. Multivariate logistic regressions were used. Results During the 5-year study period, 1915 consecutive patients were intubated in the MICUs participating in the study. Overall, 1287 (70%) patients were successfully intubated after the first laryngoscopic attempt, with rates of 90, 74, 42, and 30% for Cormack-Lehane grade 1, 2, 3, and 4, respectively. Tracheal intubation was difficult in 663 cases (36%). Tracheal intubation-related complications occurred in 267 (14%) patients. In the multivariate analysis, we found that the leading risk factors for tracheal intubation-related complications were Cormack and Lehane grade 3 and 4 [odds ratio (OR) = 1.65; 95% confidence interval (CI), 1.05-2.61; and OR = 2.79; 95% CI, 1.56-4.98, respectively], a BMI of more than 30 (OR = 1.61; 95% CI, 1.13-2.28), when intubation was difficult (OR = 1.72; 95% CI, 1.15-2.57), and when tracheal intubation required more than one operator (OR = 2.30; 95% CI, 1.50-3.49).Conclusions In this prospective study, we found that Cormack and Lehane more than grade 2, BMI >30, difficult intubation, and tracheal intubation requiring more than one operator were all independent predictors of tracheal intubation-related complications in the prehospital setting. When these risk factors are identified on scene, adapted algorithms that anticipate the use of a bougie should be generalized to reduce morbidity on the prehospital field.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults

INTRODUCTION

We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy.

METHODS

In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique.

RESULTS

Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85).

CONCLUSIONS

There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

A narrative review of the training structure, role, and safety profile of advanced critical care practitioners in adult intensive services in the United Kingdom

OBJECTIVE

Advanced clinical practitioners are a growing part of the National Health Service workforce in the United Kingdom (UK). The concept stems from the progression of skills, knowledge, and experience of healthcare professionals (including nursing, physiotherapists, paramedics, and pharmacists) to a higher level of practice. The addition of advanced critical care practitioners (ACCPs) to the multidisciplinary team of the UK adult critical care is recent; they form part of the fabric of the advanced clinical practitioner workforce. This is a narrative review of the role of ACCPs, considering the evolution of the role, training, accreditation, and evidence supporting the safety profile in adult intensive care in the UK.

METHOD

This is a narrative review.

CONCLUSION

ACCPs have evolved from an ad hoc and local training structure, to a UK-wide competency standard and training developed within the Faculty of Intensive Care Medicine. This formed in concert with the advanced clinical practitioner concept. As advanced practice is very much multiprofessional in the UK, a single regulator for multiple base professions is likely neither feasible nor realistic. Over the last 5 years, the UK picture of advanced practice has slowly standardised; an ACCP securely fits under the advanced clinical practitioner umbrella. The ACCP workforce has moved from a handful of early adopters, regional hubs, to a position across most critical care units now have or are developing a team of practitioners. The evidence base for the safety profile of ACCPs is evolving and shows parity in outcomes in the areas currently investigated. The ACCP role provides a vision of a multiprofessional workforce for the future of staffing of critical care services that is diverse and inclusive, not with the intention of competing with our medical colleagues.

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed

PURPOSE

The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI.

METHODS

The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information.

RESULTS

In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently.

CONCLUSION

Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.

Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts

BACKGROUND

Lower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS's association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services.

METHODS

This was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data.

RESULTS

Of 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66-1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications.

CONCLUSION

FPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.

The Difficult Airway Redefined

There is no all-encompassing or universally accepted definition of the difficult airway, and it has traditionally been approached as a problem chiefly rooted in anesthesiology. However, with airway obstruction reported as the second leading cause of mortality on the battlefield and first-pass success (FPS) rates for out-of-hospital endotracheal intubation (ETI) as low as 46.4%, the need to better understand the difficult airway in the context of the prehospital setting is clear. In this review, we seek to redefine the concept of the “difficult airway” so that future research can target solutions better tailored for prehospital, and more specifically, combat casualty care. Contrasting the most common definitions, which narrow the scope of practice to physicians and a handful of interventions, we propose that the difficult airway is simply one that cannot be quickly obtained. This implies that it is a situation arrived at through a multitude of factors, namely the Patient, Operator, Setting, and Technology (POST), but also more importantly, the interplay between these elements. Using this amended definition and approach to the difficult to manage airway, we outline a target-specific approach to new research questions rooted in this system-based approach to better address the difficult airway in the prehospital and combat casualty care settings.

Tracheal Intubation during Advanced Life Support Using Direct Laryngoscopy versus Glidescope® Videolaryngoscopy by Clinicians with Limited Intubation Experience: A Systematic Review and Meta-Analysis

The use of the Glidescope® videolaryngoscope might improve tracheal intubation performance in clinicians with limited intubation experience, especially during cardiopulmonary resuscitation (CPR). The objective of this systematic review and meta-analysis is to compare direct laryngoscopy to Glidescope® videolaryngoscopy by these clinicians. PubMed/Medline and Embase were searched from their inception to 7 July 2020 for randomized controlled trials, including simulation studies. Studies on adult patients or adult-sized manikins were included when direct laryngoscopy was compared to Glidescope® videolaryngoscopy by clinicians with limited experience in tracheal intubation (<10 intubations per year). The primary outcome was the intubation first-pass success rate. Secondary outcomes were time to successful intubation and chest compression interruption duration during intubation. The risk of bias was assessed with the Cochrane risk of bias tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). We included 4 clinical trials with 525 patients and 20 manikin trials with 2547 intubations. Meta-analyses favored Glidescope® videolaryngoscopy over direct laryngoscopy regarding first-pass success (clinical trials: risk ratio [RR] = 1.61; 95% confidence interval [CI]: 1.16−2.23; manikin trials: RR = 1.17; 95% CI: 1.09−1.25). Clinical trials showed a shorter time to achieve successful intubation when using the Glidescope® (mean difference = 17.04 s; 95% CI: 8.51−25.57 s). Chest compression interruption duration was decreased when using the Glidescope® videolaryngoscope. The certainty of evidence ranged from very low to moderate. When clinicians with limited intubation experience have to perform tracheal intubation during advanced life support, the use of the Glidescope® videolaryngoscope improves intubation and CPR performance compared to direct laryngoscopy.

A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation

PURPOSE

The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries.

METHODS

We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months.

CONCLUSIONS

The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa

Introduction

Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success.

Methods

This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS.

Results

A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS.

Conclusion

This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00688-4.

Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM)

Background

Pre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic—termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM.

Methods

A retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015–2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher’s exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines.

Results

In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28–63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs—90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7–2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt.

Conclusion

In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.

Ventilator Associated Pneumonia and Intubation Location in Adults with Traumatic Injuries: Systematic Review and Meta-analysis

BACKGROUND

Ventilator associated pneumonia (VAP) is an important cause of morbidity and mortality among critically ill patients, particularly those who present with traumatic injuries. This review aims to determine whether patients with traumatic injuries who are intubated in the prehospital setting are at higher risk of developing VAP compared to those intubated in the hospital.

METHODS

A systematic review of Medline, Scopus and Cochrane electronic databases was conducted from inception through January 2021. Inclusion criteria were patients with traumatic injuries who were intubated in the prehospital or hospital settings with VAP as an outcome. Using a random effects model, the risk of VAP across study arms was compared by calculating a summary relative risk (RR) with 95% confidence intervals (CI). The results of individual studies were also summarized qualitatively.

RESULTS

The search identified 754 articles of which 6 studies (N = 2990) met inclusion criteria. All studies were good quality based on assessment with the Newcastle Ottawa scale. Prehospital intubation demonstrated an increased risk of VAP development in 2 of the 6 studies. Among the 6 studies, the overall quality weighted risk ratio was 1.09 (95% CI 0.90-1.31).

CONCLUSIONS

Traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared to those that are intubated in the hospital setting.

LEVEL OF EVIDENCE

Level IV systematic review and meta-analysis.

Impact of Operator Medical Specialty on Endotracheal Intubation Rates in Prehospital Emergency Medicine—A Retrospective Cohort Study

Prehospital endotracheal intubation (ETI) can be challenging, and the risk of complications is higher than in the operating room. The goal of this study was to compare prehospital ETI rates between anaesthesiologists and non-anaesthesiologists. This retrospective cohort study compared prehospital interventions performed by either physicians from the anaesthesiology department (ADP) or physicians from another department (NADP, for non-anaesthesiology department physicians). The primary outcome was the prehospital ETI rate. Overall, 42,190 interventions were included in the analysis, of whom 68.5% were performed by NADP. Intubation was attempted on 2797 (6.6%) patients, without any difference between NADPs and ADPs (6.5 versus 6.7%, p = 0.555). However, ADPs were more likely to proceed to an intubation when patients were not in cardiac arrest (3.4 versus 3.0%, p = 0.026), whereas no difference was found regarding cardiac arrest patients (65.2 versus 67.7%, p = 0.243) (p for homogeneity = 0.005). In a prehospital physician-staffed emergency medical service, overall ETI rates did not depend on the frontline operator’s medical specialty background. ADPs were, however, more likely to proceed with ETI than NADPs when patients were not in cardiac arrest. Further studies should help to understand the reasons for this difference.

Association between case volume and mortality in pre-hospital anaesthesia management: a retrospective observational cohort

BACKGROUND

Pre-hospital anaesthesia is a core competency of helicopter emergency medical services (HEMS). Whether physician pre-hospital anaesthesia case volume affects outcomes is unknown in this setting. We aimed to investigate whether physician case volume was associated with differences in mortality or medical management.

METHODS

We conducted a registry-based cohort study of patients undergoing drug-facilitated intubation by HEMS physician from January 1, 2013 to August 31, 2019. The primary outcome was 30-day mortality, analysed using multivariate logistic regression controlling for patient-dependent variables. Case volume for each patient was determined by the number of pre-hospital anaesthetics the attending physician had managed in the previous 12 months. The explanatory variable was physician case volume grouped by low (0-12), intermediate (13-36), and high (≥37) case volume. Secondary outcomes were characteristics of medical management, including the incidence of hypoxaemia and hypotension.

RESULTS

In 4818 patients, the physician case volume was 511, 2033, and 2274 patients in low-, intermediate-, and high-case-volume groups, respectively. Higher physician case volume was associated with lower 30-day mortality (odds ratio 0.79 per logarithmic number of cases [95% confidence interval: 0.64-0.98]). High-volume physician providers had shorter on-scene times (median 28 [25th-75th percentile: 22-38], compared with intermediate 32 [23-42] and lowest 32 [23-43] case-volume groups; P<0.001) and a higher first-pass success rate for tracheal intubation (98%, compared with 93% and 90%, respectively; P<0.001). The incidence of hypoxaemia and hypotension was similar between groups.

CONCLUSIONS

Mortality appears to be lower after pre-hospital anaesthesia when delivered by physician providers with higher case volumes.

Reasons behind failed prehospital intubation attempts while combining C-MAC videolaryngoscope and Frova introducer

BACKGROUND

High first-pass success rate is achieved with the routine use of C-MAC videolaryngoscope and Frova introducer. We aim to identify potential reasons and subgroups associated with failed intubation attempts, analyse actions taken after them and study possible complications.

METHODS

We conducted a retrospective observational study of adult intubated patients at a single helicopter emergency medical service unit in southern Finland between 2016 and 2018. We collected data on patient characteristics, reasons for failed attempts, complications and follow-up measures from a national helicopter emergency medical service database and from prehospital patient records.

RESULTS

1011 tracheal intubations were attempted. First attempt was successful in 994 cases (FPS 994/1011, 98.3%), 15 needed a second or third attempt and two a surgical airway (non-FPS 17/1011, 1.7%, 95% CI 1.0-2.7). The failed first attempt group had heterogenous characteristics. The most common cause for a failed first attempt was obstruction of the airway by vomit, food, mucus or blood (10/13, 76%). After the failed first attempt, there were six cases (6/14, 43%) of deviation from the protocol and the most frequent complications were five cases (5/17, 29%) of hypoxia and four cases (4/17, 24%) of hypotension.

CONCLUSIONS

When a protocol combining the C-MAC videolaryngoscope and Frova introducer is used, the most common reason for a failed first attempt is an airway blocked by gastric content, blood or mucus. These findings highlight the importance of effective airway decontamination methods and questions the appropriateness of anatomically focused pre-intubation assessment tools when such protocol is used.

Prehospital airway management in the pediatric patient: A systematic review

BACKGROUND

Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag-valve-mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management.

METHODS

We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed study quality using the Newcastle-Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes.

RESULTS

Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24-h mortality to 1-month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta-analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies.

CONCLUSIONS

In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice.

Comparison of clinical methods to diagnose pediatric endobronchial intubation-A randomized controlled trial

Background and Aims:

Diagnosing accurate placement of the tip of the endotracheal tube is crucial in pediatric practice. This study was conducted to find out the efficacy of five clinical methods to ascertain the tube position by a resident anesthesiologist.

Material and Methods:

This was a randomized crossover study conducted in a research institute. Fifty pediatric patients were enrolled. All patients were randomly allocated to tracheal (group T) or bronchial group (group B). The five clinical methods which were evaluated include the auscultation, observation of chest movements, bag compliance, tube depth, and capnography. In group T, the tube was placed in the trachea and later positioned in bronchus (assisted by fiberoptic bronchoscopy). The vice versa was done in group B. In each position, a single test followed by all tests was performed and after the change of position, the same single test followed by all tests was performed. Correct and incorrect diagnoses by tests in detecting tube positions were made and their sensitivity and odds ratio were estimated.

Results:

The tube depth and combination of all tests detected endobronchial intubation with a sensitivity of 88% and 97%, respectively, which is more than that of auscultation (70%) and observation (55%). Evaluation of the difference in agreement level of tube depth to detect tube-position showed the odds ratio of 2.28 (0.17–30.95) for detecting endobronchial intubation.

Conclusion:

We observed that the tube-depth was better than the other individual tests in diagnosing endobronchial intubation in pediatric patients. However, its efficacy is lesser than that of performing all clinical tests together.

Pre-hospital critical care at major incidents

The identification, triage, and extrication of casualties followed by on-scene management and transport to an appropriate hospital after mass casualty incidents can be complicated, delivered to variable standards, and add significant delays to care. An effective pre-hospital pathway can both increase the chances of survival of individual patients and significantly influence the effectiveness of the entire emergency response.

Comparison of direct laryngoscopy and video-assisted laryngoscopy in pediatric intensive care unit

Our objective was to compare video-assisted laryngoscopy (VAL) with direct laryngoscopy (DL) for glottic visualization in a pediatric intensive care unit in terms of the success rate in first attempts. Our study included patients aged from 1 month to 18 years who were admitted to the pediatric intensive care unit. We excluded patients with limited neck extension (C-spine immobilization, congenital abnormality), congenital anomalies (e.g., Pierre Robin syndrome, micrognathia, macroglossia), and recent airway surgery. Patients were premedicated before intubation. The time to intubation was defined as the time between the start of anesthesia and completion of intubation. The start of anesthetic induction was defined as the time the sedative was first administered. Completion of intubation was defined as the time that the end-tidal carbon dioxide tension was detected. We evaluated 120 of 135 intubations that met our inclusion criteria; 15 were excluded because in eight cases (53%) non-pediatric intensive care physicians made the initial attempts, and in seven cases (47%) the recorded intubation times were erroneous. We detected significantly higher POGO scores in the VAL group (p<0.001). VAL provided a fuller view of the glottis (Cormack and Lehane grade 1) than DL (p<0.001). Although the intubation attempts in the DL group were significantly higher (two or more attempts), no intubation failures occurred in either group.

Establishing quality indicators for prehospital advanced airway management: a modified nominal group technique consensus process

Background

Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management.

Methods

We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria.

Results

Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications.

Conclusions

We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams

Background

Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult.

Method

The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality.

Result

The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED.

Conclusion

Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

PURPOSE

Swiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries.

METHODS

The TraumaRegister DGU® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups.

RESULTS

Swiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries.

CONCLUSION

This study demonstrates that patients' age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.