Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies.

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Project for Universal Management of Airways - part 1: concept and methods.

Multiple professional groups and societies worldwide have produced airway management guidelines. These are typically targeted at the process of tracheal intubation by a particular provider group in a restricted category of patients and reflect practice preferences in a particular geographical region. The existence of multiple distinct guidelines for some (but not other) closely related circumstances, increases complexity and may obscure the underlying principles that are common to all of them. This has the potential to increase cognitive load; promote the grouping of ideas in silos; impair teamwork; and ultimately compromise patient care. Development of a single set of airway management guidelines that can be applied across and beyond these domains may improve implementation; promote standardisation; and facilitate collaboration between airway practitioners from diverse backgrounds. A global multidisciplinary group of both airway operators and assistants was assembled. Over a 3-year period, a review of the existing airway guidelines and multiple reviews of the primary literature were combined with a structured process for determining expert consensus. Any discrepancies between these were analysed and reconciled. Where evidence in the literature was lacking, recommendations were made by expert consensus. Using the above process, a set of evidence-based airway management guidelines was developed in consultation with airway practitioners from a broad spectrum of disciplines and geographical locations. While consistent with the recommendations of the existing English language guidelines, these universal guidelines also incorporate the most recent concepts in airway management as well as statements on areas not widely addressed by the existing guidelines. The recommendations will be published in four parts that respectively address: airway evaluation; airway strategy; airway rescue and communication of airway outcomes. Together, these universal guidelines will provide a single, comprehensive approach to airway management that can be consistently applied by airway practitioners globally, independent of their clinical background or the circumstances in which airway management occurs.

Strategies to improve first attempt success at intubation in critically ill patients.

Tracheal intubation in critically ill patients is a high-risk procedure. The risk of complications increases with repeated or prolonged attempts, making expedient first attempt success the goal for airway management in these patients. Patient-related factors often make visualization of the airway and placement of the tracheal tube difficult. Physiologic derangements reduce the patient's tolerance for repeated or prolonged attempts at laryngoscopy and, as a result, hypoxaemia and haemodynamic deterioration are common complications. Operator-related factors such as experience, device selection, and pharmacologic choices affect the odds of a successful intubation on the first attempt. This review will discuss the 'difficult airway' in critically ill patients and highlight recent advances in airway management that have been shown to improve first attempt success and decrease adverse events associated with the intubation of critically ill patients.

A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients.

OBJECTIVE: To compare rocuronium and succinylcholine for rapid-sequence intubation (RSI) in the emergency department (ED). METHODS: A one-year prospective cohort comparison study was performed using a data collection form completed at the time of intubation. Data collected included the reason for the neuromuscular-blocking agent (NMBA) chosen, the time to onset of paralysis, and any complications encountered. Three ten-point numerical descriptor scales recorded the degree of body movement, vocal cord movement, and the physician's overall satisfaction with the extent of paralysis. RESULTS: Succinylcholine was used in 382 patients and rocuronium was used in 138 (26% of all RSI) patients. The mean (+/- SD) times of onset of succinylcholine and rocuronium were 39 +/- 13 sec and 44 +/- 20 sec, respectively (p = 0.04). No patient desaturated and required assisted ventilations while waiting for paralysis to occur. Types of body movements were similar with the two agents, but less frequent with succinylcholine (median = 10, mean = 9.5 +/- 1.1) than rocuronium (median = 10, mean = 9.1 +/- 1. 5) (p = 0.01). Vocal cord movements were similar for succinylcholine (median = 10, mean = 9.2 +/- 1.6) and rocuronium (median = 9, mean = 9.0 +/- 1.6) (p = 0.15). The physician's overall satisfaction with the extent of paralysis was also higher for succinylcholine (median = 10, mean = 9.4 +/- 1.3) than rocuronium (median = 10, mean = 8.8 +/- 2.0) (p < 0.01). Only one complication, widening of the QRS complex secondary to succinylcholine use in a patient with unsuspected hyperkalemia, could be attributed to the choice of NMBA. CONCLUSIONS: Both succinylcholine and rocuronium produced fast and reliable paralysis for RSI. Although succinylcholine had a faster onset and provided more relaxation, the difference had no clinical significance. Approximately a fourth of ED RSI patients qualified for use of rocuronium using these high-risk criteria.

Rocuronium for rapid sequence intubation of emergency department patients.

Rocuronium is a recently synthesized non-depolarizing neuromuscular blocking agent (NMBA) that has been demonstrated to have a faster onset of action than any other non-depolarizing NMBA. Although widely studied in the operating room, there are no reports regarding its use for emergent tracheal intubation in the emergency department (ED). The purpose of this study was to evaluate the use of rocuronium for rapid sequence intubation (RSI) in ED patients. An intubation data collection form was completed prospectively for any patient receiving rocuronium for RSI in the ED from July 1-December 31, 1997. Two hundred eighty-eight patients were intubated in the ED over this six-month period, of whom 261 (91%) underwent RSI. Fifty-eight of the patients undergoing RSI received rocuronium for paralysis (22%). The most common reason reported for use of rocuronium was a concern regarding hyperkalemia (53%). The mean dose used was 1.0 +/- 0.2 mg/kg. The mean onset to paralysis was 45 +/- 15 s. Of the complications reported, none appeared to be related to rocuronium. Use of rocuronium in the ED setting appears useful.

Teaching basic EMTs endotracheal intubation: can basic EMTs discriminate between endotracheal and esophageal intubation?

HYPOTHESIS: Advanced airway intervention techniques are being considered for use by basic emergency medical technicians (EMTs). It was hypothesized that basic EMTs would be able to discriminate reliably between intratracheal and esophageal endotracheal tube placement in a mannequin model. DESIGN: An airway mannequin with a closed chest cavity was intubated randomly either esophageally or tracheally, and the cuff was inflated. A stethoscope, bag ventilator, and laryngoscope were available next to the mannequin. Placement was assessed by auscultation or direct visualization at the discretion of the EMT. A blinded investigator graded the student. SETTING: A classroom in a large, urban medical center. PARTICIPANTS: Subjects were basic EMTs who volunteered to take part after the conclusion of a six-hour endotracheal intubation training course. RESULTS: Thirty-three subjects were tested. Seventeen of 18 (94%) tracheal intubations and 11 of 15 (73%) esophageal intubations were identified correctly. Only 72% of the students listened to the epigastrium, 81% listened to the lungs, and 85% attempted ventilation. The 10 students who visualized the cords discovered all five esophageal intubations. The 23 students who did not visualize the cords missed four and found six esophageal intubations. CONCLUSION: Basic EMTs had difficulty assessing endotracheal tube placement in a mannequin model. The 27% miss rate for identifying esophageal intubations suggests that basic EMTs will require additional training for safe field use of any airway that requires assessment of tube placement.

Effect of immediate fluid resuscitation on the rate, volume, and duration of pulmonary vascular hemorrhage in a sheep model of penetrating thoracic trauma.

STUDY OBJECTIVE: To determine the effects of early fluid resuscitation on the rate, volume, and duration of hemorrhage using a sheep model of uncontrolled pulmonary vascular hemorrhage. METHODS: Sixteen adult sheep were anesthetized and fitted with catheters to measure systemic and pulmonary artery pressures. A branch of the pulmonary vein was then lacerated through an anterolateral thoracotomy, and a chest tube was inserted to monitor hemorrhage volume. Eight animals were assigned to the immediate fluid (IF) resuscitation group and were given 30 mL/kg of lactated Ringer's solution over a period of 10 minutes; this treatment was repeated once if normotension was not achieved. The other eight animals received no fluid (NF) and served as nonresuscitated controls. RESULTS: The IF animals had a mean hemorrhage volume of 3,494 +/- 1,525 mL, compared with 1,594 +/- 689 mL in the NF group (P < .001). Hemorrhage stopped spontaneously in the NF group at a mean of 29 +/- 9 minutes but took 48 +/- 11 minutes in the IF group (P = .003). During the 20-minute period of fluid resuscitation, the IF animals bled at twice the rate of the NF animals (90 +/- 33 versus 46 +/- 22 mL/minute, respectively; P = .02). During the 10-minute interval after fluids were administered, the rate of hemorrhage remained brisk at 73 +/- 57 mL/minute in the IF group but virtually stopped in the NF group (6 +/- 7 mL/minute; P = .02). CONCLUSION: In this sheep model of uncontrolled pulmonary vascular hemorrhage, immediate fluid resuscitation significantly increased the rate, volume, and duration of hemorrhage. The vigorous administration of fluids to patients with penetrating chest trauma has the potential to significantly increase blood loss.

Comparison of 2 cricothyrotomy techniques: standard method versus rapid 4-step technique.

STUDY OBJECTIVE: To compare the success rate, complication rate and time required for the rapid 4-step technique versus the standard technique for cricothyrotomy. METHODS: We conducted a prospective, randomized crossover study. Twenty-seven emergency medicine interns, 1 junior medicine resident, and 4 senior medical students, without prior cricothyrotomy experience, were randomly divided into 2 groups. Group 1 was initially instructed in and then performed the standard technique; group 2 was initially instructed in and then performed the rapid 4-step technique. Each group was then instructed in and performed the alternate method. Cricothyrotomies were performed on preserved human cadavers. RESULTS: A surgical airway was established in 28 of 32 attempts with the use of the rapid 4-step technique (88%); the average time elapsed before tube placement was 43 seconds. Thirty of 32 attempts involving the standard technique (94%) were successful; the average time to tube placement was 134 seconds (95% confidence interval for a difference of 91 seconds, 63 to 119; P < .001). Complications were identified in 12 attempts involving the standard technique (38%; 1 considered major) and in 12 involving the rapid four-step technique (38%; 3 considered major). The incidence of major complications was 6% higher for the rapid 4-step technique (95% confidence interval, -9% to 21%). CONCLUSION: In a group of inexperienced subjects working on a preserved human cadaver model, the rapid 4-step technique for cricothyrotomy was performed in about one third the time required for performance of the standard technique. This finding was both clinically and statistically significant. Although the 2 techniques had similar success and complication rates, we noted a trend toward more severe complications in the rapid 4-step technique.

Airway management in the emergency department: a one-year study of 610 tracheal intubations.

STUDY OBJECTIVE: To describe the methods, success rates, and immediate complications of tracheal intubations performed in the emergency department of an urban teaching hospital. METHODS: This was an observational, consecutive series undertaken in an urban university hospital with an emergency medicine residency training program and an annual ED census of 60,000 patients. The study population included all patients for whom intubation was attempted in the ED during a 1-year period (July 1, 1995 through June 30, 1996). At the time of each intubation, the intubator filled out an intubation data collection form. If an intubation was performed in the ED but no form was filled out, the data were obtained from the medical record. RESULTS: A total of 610 patients required airway control in the ED; 569 (93%) were intubated by emergency medicine residents or attending physicians. Rapid-sequence intubation (RSI) was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated; 7 patients could not be intubated and underwent cricothyrotomy. In 33 patients, inadvertent placement into the esophagus occurred; all such situations were rapidly recognized and corrected. Eight (24%) of the 33 esophageal intubations resulted in a reported immediate complication. Overall, 49 patients (8.0%; 95% confidence interval [CI], 6% to 11%) experienced a total of 57 immediate complications (9.3%; 95% CI, 7% to 12%). Three patients sustained a cardiac arrest after intubation; two of these patients had agonal rhythms before intubation, and one probably had a succinylcholine-induced hyperkalemic cardiac arrest. CONCLUSION: At this institution, the majority of ED intubations were performed by emergency physicians and RSI was the most common method used. Emergency physicians intubated critically ill and injured ED patients with a very high success rate and a low rate of serious complications.

Field trial of endotracheal intubation by basic EMTs.

STUDY OBJECTIVE: The 1994 basic-EMT (EMT-B) curriculum recommended teaching EMT-Bs the skill of endotracheal intubation. In this study we assessed the success and complication rates of endotracheal intubations in the field by EMT-Bs. METHODS: We conducted a prospective clinical trial over a period of 28 months in an urban out-of-hospital EMS system. Four first-responder EMT-B engine companies with paramedic backup received 10 hours; intubation training in three sessions spread over at least 2 weeks. The training module was similar to that of the 1994 EMT-B curriculum and included at least 10 intubations on manikins. The EMTs used manikins with closed chest cavities to learn assessment of endotracheal-tube placement. Patients were eligible for intubation by the EMTs if they were apneic and older than 15 years. We calculated 95% confidence interval (CIs) for intubation success rates. RESULTS: Sixty-six EMT-Bs passed the training examinations and were authorized to perform intubation in the field. Endotracheal intubation was attempted by EMTs in 103 patients; the attempt was successful in 53 (95% CI, 42% to 61%). All patients who were not intubated by EMT-Bs were intubated by paramedics, with the exception of six cases. One attempt at intubation was made in 52 patients, two attempts in 44, and three in 7. Three unrecognized esophageal intubations occurred. CONCLUSION: EMT-Bs trained in a short course successfully intubated about half the patients they encountered in this study. This low intubation success rate calls into question the validity of the endotracheal-intubation training module in the 1994 EMT-B national curriculum.