Field intubation of cardiac arrest patients: a dying art?

INTRODUCTION: The most appropriate advanced airway intervention in out-of-hospital cardiac arrest (OHCA) is unproven. This study reviews prehospital advanced airway management and its complications in OHCA patients. METHODS: A 4-year, observational, retrospective case review. Patients attending the Emergency Department of the Royal Infirmary of Edinburgh, Scotland, with a primary diagnosis of OHCA were identified. Patient demographics, survival to admission, airway management technique and complication rates were identified. RESULTS: Seven hundred and ninety-four cases were identified. The aetiology of cardiac arrest was medical in 95.2%, traumatic in 3.9% and unrecorded in 0.9%. Prehospital intubation was attempted in 628 patients. Prehospital intubation was successful in 573 patients. A significant complication (multiple attempts, displaced endotracheal tube or oesophageal intubation) occurred in 55 (8.8%) patients. 165 (20.8%) patients survived to hospital admission, of whom 110 had undergone prehospital intubation. 55 patients who did not undergo prehospital tracheal intubation survived to hospital admission. CONCLUSION: The optimal method of maintaining an airway and ventilating an OHCA patient has yet to be established. Prehospital tracheal intubation for OHCA is associated with significant complications and may reduce survival. The use of tracheal intubation as a routine intervention should be reconsidered. Ambulance services should consider adopting alternative strategies in airway management.

Catastrophe for a campanologist.

A campanologist was involved in a nonfatal hanging incident. On presentation she had no midline bony tenderness and only subtle abnormalities on plain X-ray films of her cervical spine; however, a CT scan showed a type III odontoid peg fracture. We believe this is the first reported cervical spine fracture sustained while bell-ringing. This case demonstrates the importance of mechanism of injury with regard to decisions about diagnostic imaging and the debate concerning the choice of first-line cervical imaging is highlighted.

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

AIM: The emergency department (ED) is an area where major airway difficulties can occur, often as complications of rapid sequence induction (RSI). We undertook a prospective, observational study of tracheal intubation performed in a large, urban UK ED to study this further. METHODS: We reviewed data on every intubation attempt made in our ED between January 1999 and December 2011. We recorded techniques and drugs used, intubator details, success rate, and associated complications. Tracheal intubation in our ED is managed jointly by emergency physicians and anaesthetists; an anaesthetist is contacted to attend to support ED staff when RSI is being performed. RESULTS: We included 3738 intubations in analysis. 2749 (74%) were RSIs, 361 (10%) were other drug combinations, and 628 (17%) received no drugs. Emergency physicians performed 78% and anaesthetists 22% of intubations. Tracheal intubation was successful in 3724 patients (99.6%). First time success rate was 85%; 98% of patients were successfully intubated with two or fewer attempts, and three patients (0.1%) had more than three attempts. Intubation failed in 14 patients; five (0.13%) had a surgical airway performed. Associated complications occurred in 286 (8%) patients. The incidence of complications was associated with the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p<0.001). CONCLUSION: A collaborative approach between emergency physicians and anaesthetists contributed to a high rate of successful intubation and a low rate of complications. Close collaboration in training and delivery of service models is essential to maintain these high standards and achieve further improvement where possible.

Laryngoscopic views during rapid sequence intubation in the emergency department.

OBJECTIVES: Our objective was to document and compare the views obtained at laryngoscopy during emergency department (ED) rapid sequence intubation (RSI) by anesthetists and emergency physicians of varying seniority and experience. METHODS: Data were prospectively collected on every intubation attempt in 7 urban Scottish EDs for 2 calendar years, commencing Jan. 11, 1999. Data included patient's age, gender, grade and specialty of intubator, laryngoscopic grade, and number of intubation attempts. Quality of laryngoscopic visualization was graded using the Cormack-Lehane scale, with grades I and II considered good visualization. A descriptive analysis was performed, and key statistical comparisons made. RESULTS: During the study period, 735 patients underwent RSI, and grade of intubation was documented in 672 cases (91%). In total, 68.2%, 23.4%, 6.1% and 2.4% of the intubations were classified as Cormack-Lehane grade I, II, III and IV respectively. Overall, anesthetists and anesthesia trainees achieved good laryngoscopic visualization in 94.0% of cases (95% confidence interval [CI], 90.8%-96.4%) and emergency physicians and emergency medicine trainees did so in 89.2% of cases (95% CI, 85.5%-92.3%; p = 0.027). Specialist registrars and senior house officers in anesthesia were more likely to obtain good visualization than their emergency medicine counterparts (p = 0.034 and 0.035 respectively). Consultants in emergency medicine were more likely to obtain good views than their anesthesia counterparts, but this difference was not statistically significant. CONCLUSIONS: Anesthetic trainees obtain better laryngoscopic views than emergency medicine trainees, but these differences disappear with increasing emergency physician seniority, suggesting a training and experience effect. Emergency medicine trainees may benefit from additional focus on laryngoscopic visualization techniques early in their training period.

Surgical airway in emergency department intubation.

OBJECTIVES: To determine the frequency of and primary indication for surgical airway during emergency department intubation. METHODS: Prospectively collected data from all intubations performed in the emergency department from January 1999 to July 2007 were analysed to ascertain the frequency of surgical airway access. Original data were collected on a structured proforma, entered into a regional database and analysed. Patient records were then reviewed to determine the primary indication for a surgical airway. RESULTS: Emergency department intubation was undertaken in 2524 patients. Of these, only five patients (0.2%) required a surgical airway. The most common indication for a surgical airway was trauma in four of the five patients. Two patients had attempted rapid sequence induction before surgical airway. Two patients had gaseous inductions and one patient received no drugs. In all five patients, surgical airway was performed secondary to failed endotracheal intubation attempt(s) and was never the primary technique used. CONCLUSION: In our emergency department, surgical airway is an uncommon procedure. The rate of 0.2% is significantly lower than rates quoted in other studies. The most common indication for surgical airway was severe facial or neck trauma. Our emergency department has a joint protocol for emergency intubation agreed by the Departments of Emergency Medicine, Anaesthesia and Critical Care at the Edinburgh Royal Infirmary. We believe that the low surgical airway rate is secondary to this collaborative approach. The identified low rate of emergency department surgical airway has implications for training and maintenance of skills for emergency medicine trainees and physicians.

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

AIM: Our primary objective was to evaluate the characteristics and outcomes of elderly (≥ 80 years) patients undergoing rapid sequence induction of anaesthesia and intubation (RSI) in our emergency department (ED). METHODS: We retrospectively analysed data collected prospectively between January 1999 and December 2007. We retrieved age; gender; presenting diagnosis; indication and urgency for RSI; complications related to RSI; hospital destination; and outcome. RESULTS: 1686 patients underwent RSI in the ED during the study period; 107 (6%) were aged ≥ 80 years. The mean age (range) was 84 (80-91) years. 94 patients (88%) were living in a private residence before presentation to the ED. Intracerebral haemorrhage, ischaemic stroke and head injury were the commonest presenting diagnoses. Forty-one patients were admitted to intensive care, 55 were admitted to a ward (31 for palliative care) and 11 died in the ED. Seventy-two patients (67%) died; of the 35 survivors, 21 (60%) made a good recovery with no requirement for increased social care. Outcome was worse after neurological diagnoses, sepsis and trauma than after cardiac or respiratory failure, seizures or drug overdose. Presenting diagnosis predicted outcome on univariable analysis (p<0.001), but it was not possible to calculate risk for individual diagnoses. RSI-related complications, of which hypotension was commonest, occurred in 15% of patients. CONCLUSION: A small number of patients who undergo RSI in our ED are aged ≥ 80 years. They generally have high mortality with only 20% surviving to hospital discharge with no increase in dependency; however 60% of survivors make a good recovery. In this highly selected elderly population age is not the main determinant of outcome which is influenced more by presenting diagnosis.