| Vía aérea difícil no anticipada en una situación prehospitalaria de emergencia: valoración prospectiva de un algoritmo. |
Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm.
Combes X, Jabre P, Margenet A, Merle JC, Leroux B, Dru M, Lecarpentier E, Dhonneur G.
CHU H Mondor, AP-HP, Créteil, France. xavier.combes@hmn.aphp.fr
Anesthesiology. 2011 Jan;114(1):105-10.
Abstract
BACKGROUND: Difficult intubation management algorithms have proven efficacy in operating rooms but have rarely been assessed in a prehospital emergency setting. We undertook a prospective evaluation of a simple prehospital difficult intubation algorithm. METHODS: All of our prehospital emergency physicians and nurse anesthetists were asked to adhere to a simple algorithm in all cases of impossible laryngoscope-assisted tracheal intubation. They received a short refresher course and training in the use of the gum elastic bougie (GEB) and the intubating laryngeal mask airway (ILMA), which were techniques to be used as a first and a second step, respectively. In cases of difficult ventilation with arterial desaturation, IMLA was to be used first. Cricothyroidotomy was the ultimate rescue technique when ventilation through ILMA failed. Patient characteristics, adherence to the algorithm, management efficacy, and early complications were recorded (August 2005-December 2009). RESULTS: An alternative technique to secure the airway was needed in 160 of 2,674 (6%) patients undergoing intubation. Three instances of nonadherence to the algorithm were recorded. GEB was used first in 152 patients and was successful in 115. ILMA was used first in 8 patients and second in the 37 GEB-assisted intubation failures. Forty-five patients were successfully mask-ventilated, and 42 were blindly intubated before reaching the hospital. Cricothyroidotomy was used successfully in a patient with severe upper airway obstruction as a result of pharyngeal neoplasia. Early intubation-related complications occurred in 52% difficult cases. CONCLUSION: Adherence to a simple algorithm using GEB, ILMA, and cricothyroidotomy solved all difficult intubation cases occurring in a prehospital emergency setting.http://journals.lww.com/anesthesiology/pages/articleviewer.aspx?year=2011&issue=01000&article=00026&type=abstract
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| Auto reporte de urgenciólogos sobre el entrenamiento y experiencia en el manejo de la vía aérea: estudio descriptivo de la región central de Dinamarca |
EMS-physicians' self reported airway management training and expertise; a descriptive study from the Central Region of Denmark.
Rognås LK, Hansen TM.
The Mobile Emergency Care Unit, Department of Anesthesiology, The Regional Hospital Viborg, Heibergs Allé 4, Postbox 130, 8800 Viborg, Denmark. leifrogn@rm.dk
Scand J Trauma Resusc Emerg Med. 2011 Feb 8;19:10.
Abstract
BACKGROUND: Prehospital advanced airway management, including prehospital endotracheal intubation is challenging and recent papers have addressed the need for proper training, skill maintenance and quality control for emergency medical service personnel. The aim of this study was to provide data regarding airway management-training and expertise from the regional physician-staffed emergency medical service (EMS). METHODS: The EMS in this part of The Central Region of Denmark is a two tiered system. The second tier comprises physician staffed Mobile Emergency Care Units. The medical directors of the programs supplied system data. A questionnaire addressing airway management experience, training and knowledge was sent to the EMS-physicians. RESULTS: There are no specific guidelines, standard operating procedures or standardised program for obtaining and maintaining skills regarding prehospital advanced airway management in the schemes covered by this study. 53/67 physicians responded; 98,1% were specialists in anesthesiology, with an average of 17,6 years of experience in anesthesiology, and 7,2 years experience as EMS-physicians. 84,9% reported having attended life support course(s), 64,2% an advanced airway management course. 24,5% fulfilled the curriculum suggested for Danish EMS physicians. 47,2% had encountered a difficult or impossible PHETI, most commonly in a patient in cardiac arrest or a trauma patient. Only 20,8% of the physicians were completely familiar with what back-up devices were available for airway management. CONCLUSIONS: In this, the first Danish study of prehospital advanced airway management, we found a high degree of experience, education and training among the EMS-physicians, but their equipment awareness was limited. Check-outs, guidelines, standard operating procedures and other quality control measures may be needed.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045910/pdf/1757-7241-19-10.pdf
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| Comparación de McGrath® Series 5 y del GlideScope® Ranger con el laringoscopio Macintosh por paramédicos |
Comparison of the McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope by paramedics.
Piepho T, Weinert K, Heid FM, Werner C, Noppens RR.
Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University-Mainz, Langenbeckstrasse 1, Mainz, Germany.
Scand J Trauma Resusc Emerg Med. 2011 Jan 17;19(1):4.
Abstract
BACKGROUND:
Out-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath® Series 5 and GlideScope® Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics. METHODS: Thirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated.RESULTS: Time until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath® compared to the GlideScope® and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath® device (p < 0.001) compared to using the Macintosh blade. CONCLUSIONS: The learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath® and GlideScope® devices by paramedics
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032718/pdf/1757-7241-19-4.pdf
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| Efecto de la supervisión médica intensiva en un programa de la intubación prehospitalaria de secuencia rápida |
Effect of intensive physician oversight on a prehospital rapid-sequence intubation program.
Cushman JT, Zachary Hettinger A, Farney A, Shah MN.
Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA. jeremycushman@urmc.rochester.edu
Prehosp Emerg Care. 2010 Jul-Sep;14(3):310-6.
Abstract
OBJECTIVE: To examine the effects of adding close concurrent and retrospective physician oversight, consistent with National Association of EMS Physicians (NAEMSP) recommendations, to an existing regional prehospital rapid-sequence intubation (RSI) program. METHODS: This study involved a retrospective cohort of patients receiving RSI between January 1, 2004, and July 31, 2008. On January 1, 2007, an updated program including additional concurrent and retrospective physician oversight, increased RSI-specific continuing medical education, and cadaver laboratory training was implemented. Study patients were divided into a preintervention group (group 1) and a postintervention group (group 2) based on date of medical care. Data regarding baseline characteristics, airway management, medication usage, and performance factors were compared between the groups. A retrospective review by two emergency medical services (EMS) physicians assessed whether the RSI was "clearly indicated" based on a predetermined set of criteria. RESULTS: There were 109 RSIs performed in group 1 and 54 in group 2. Absolute increases in the use of both basic life support (BLS) (5%, p = 0.2) and advanced life support (ALS) (41%, p = 0.001) airway techniques were observed. Increases in postintubation administration of midazolam (30%, p = 0.001) and morphine (24%, p = 0.001) and a decrease for vecuronium (-28%, p = 0.001) were observed. There was no statistically significant difference in the intubation success rates (92% vs. 94%) and the frequencies of recognized esophageal endotracheal tube (ETT) placement (5% vs. 6%). The number of unrecognized esophageal ETT placements remained zero. Physician chart review demonstrated an absolute increase in "clearly indicated" RSIs (17%, p = 0.01). CONCLUSIONS: Close concurrent and retrospective physician oversight consistent with recommendations from the NAEMSP is associated with improved cognitive skills in paramedics, including appropriate patient selection for RSI. Further research is warranted to validate this model and optimize where resources are best used to enhance patient safety and improve clinical management for this controversial paramedic skill.
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