Risk factors for failed first intubation attempt in an out-of-hospital setting: a multicenter prospective study.

This study was performed to identify variables potentially associated with failure of the first intubation attempt in an out-of-hospital emergency setting, considering all aspects of tracheal intubation. This observational prospective multicenter study was performed over 17 months and involved 10 prehospital emergency medical units. After each tracheal intubation, the operator was required to provide information concerning operator and patient characteristics, as well as the environmental conditions during intubation, by completing a data collection form. The primary endpoint was failure of the first intubation attempt. During the study period, 1546 patients were analyzed, of whom 59% were in cardiac arrest; 486 intubations failed on the first attempt (31.4% [95% confidence interval = 30.2-32.6]). Multivariate analysis revealed that the following 7 of 28 factors were associated with an increased risk of a failed first intubation attempt: operator with fewer than 50 prior intubations (odds ratio [OR] = 1.8 [1.4-2.4]), small inter-incisor space (OR = 2.3 [1.7-3.2]), limited extension of the head (OR = 1.6 [1.1-2.1]), macroglossia (OR = 2.3 [1.6-3.2]), ear/nose/throat (ENT) tumor (OR = 4.4 [1.4-13.4]), cardiac arrest (OR = 1.8 [1.3-2.6]), and vomiting (OR = 1.7 [1.3-2.3]). The frequency of adverse events among non-cardiac arrest patients was 17.6%; it increased with each additional intubation attempt. The first intubation attempt failed in more than 30% of cases, and seven variables were associated with increased risk of failure. Most of these factors could not be predicted.

Point-of-care ultrasonography for risk stratification of non-critical suspected COVID-19 patients on admission (POCUSCO): A prospective binational study.

BACKGROUND: Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening. METHODS: POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion. RESULTS: Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 [95%CI:0.60-0.94]. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and ≥16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%[95%CI:0-3.9]) for low-risk patients (score = 0), 4/184 (2.17%[95%CI:0.8-5.5]) for intermediate-risk patients (score 1-15) and 4/17 (23.5%[95%CI:11.4-42.4]) for high-risk patients (score ≥16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 [95%CI:0.92-1.00]. CONCLUSION: L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.