Guest guest Posted October 25, 2008 Report Share Posted October 25, 2008 Prehosp Emerg Care. 2008 Oct-Dec;12(4):459-66. Distance impacts mortality in trauma patients with an intubation attempt. Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA. michael.cudnik@... OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been associated with adverse outcomes; whether transport distance changes this relationship is unclear. We sought to determine whether patients injured farther from the hospital benefit more from OOH-ETI than those injured closer. METHODS: We performed a retrospective cohort analysis of trauma patients > 14 years old transported to two Level 1 trauma centers and surviving to admission from 2000 to 2003. We used probabilistically linked geographic data to calculate transport distance. To adjust for the nonrandom selection of patients for OOH-ETI, we used a propensity score based on clinical variables: prehospital physiology, demographics, transport mode, mechanism, comorbidities, Abbreviated Injury Scale head injury score >or= 3, Injury Severity Score, blood transfusion, and major surgery. Propensity-adjusted multivariable logistic regression with mode of transport was used to test the interaction between distance and OOH-ETI. RESULTS: 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI had higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.33-3.18), and there was a significant interaction between distance and OOH-ETI (p = 0.02). Patients with shortest distances had the highest mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was higher with OOH-ETI across all distances and increased for patients closest to the hospital. Helicopter transport was associated with improved survival. CONCLUSIONS: Prehospital intubation is associated with increased mortality among trauma patients at all distances from the hospital. Patients with the shortest transport distances had the greatest mortality associated with OOH-ETI, whereas helicopter transport was associated with improved survival. The event location and ensuing distance to the hospital are another factor to consider when instituting and modifying OOH airway protocols. E. Bledsoe, DO, FACEP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 25, 2008 Report Share Posted October 25, 2008 Is this perhaps because the intubated patients were sicker to begin with? What factors caused the HEMS patients to do better? GG > > Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp > > Distance impacts mortality in trauma patients with an intubation attempt. > > Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. > Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, > USA. michael.cudnik@... > > OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been > associated with adverse outcomes; whether transport distance changes this > relationship is unclear. We sought to determine whether patients injured > farther from the hospital benefit more from OOH-ETI than those injured > closer. METHODS: We performed a retrospective cohort analysis of trauma > patients > 14 years old transported to two Level 1 trauma centers and > surviving to admission from 2000 to 2003. We used probabilistically linked > geographic data to calculate transport distance. To adjust for the nonrandom > selection of patients for OOH-ETI, we used a propensity score based on > clinical variables: prehospital physiology, demographics, transport mode, > mechanism, comorbidities, Abbreviated Injury Scale head injury score >or= 3, > Injury Severity Score, blood transfusion, and major surgery. > Propensity-adjusted multivariable logistic regression with mode of transport > was used to test the interaction between distance and OOH-ETI. RESULTS: > 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI had > higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence interval > [CI] 1.33-3.18), and there was a significant interaction between distance > and OOH-ETI (p = 0.02). Patients with shortest distances had the highest > mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was higher > with OOH-ETI across all distances and increased for patients closest to the > hospital. Helicopter transport was associated with improved survival. > CONCLUSIONS: Prehospital intubation is associated with increased mortality > among trauma patients at all distances from the hospital. Patients with the > shortest transport distances had the greatest mortality associated with > OOH-ETI, whereas helicopter transport was associated with improved survival. > The event location and ensuing distance to the hospital are another factor > to consider when instituting and modifying OOH airway protocols. > > E. Bledsoe, DO, FACEP > > > ************** Play online games for FREE at Games.com! All of your favorites, no registration required and great graphics – check it out! (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= http://www.games.com?ncid=emlcntusgame00000001) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 26, 2008 Report Share Posted October 26, 2008 I posted the full article to my FTP site: http://www.mediafire.com/?zhj4niiyz3m From: Paramedicine [mailto:Paramedicine ] On Behalf Of Larry Torrey Sent: Sunday, October 26, 2008 12:28 PM To: Paramedicine Subject: Re: Intubation in Trauma I agree with that. Obviously I have not read the entire study, so I can't comment on the details. Given only the abstract, I wonder if they would have drawn the same conclusions if they evaluated the number of repeat set of vital signs and how they correlate to mortality. My guess is that those who die have been subjected to more BP measurements than those who survived. It's intuitive that sicker people (at least in my world) are more likely to be intubated enroute than those who aren't so sick. It's also intuitive that sicker people are more likely to die. Regarding distances, I'd also argue that I perceive you to be even sicker if I've taken the time to intubate you a short distance away from the hospital, rather than just bag you, etc., for a mile. So...like vital signs assessment, is this a sx of the problem, or is there a causal relationship? LT wegandy1938@... <mailto:wegandy1938%40aol.com> wrote: > Is this perhaps because the intubated patients were sicker to begin with? > > What factors caused the HEMS patients to do better? > > GG > In a message dated 10/25/08 10:58:59 AM, bbledsoe@... <mailto:bbledsoe%40earthlink.net> writes: > > >> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >> >> Distance impacts mortality in trauma patients with an intubation attempt. >> >> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >> Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, >> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> >> >> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >> associated with adverse outcomes; whether transport distance changes this >> relationship is unclear. We sought to determine whether patients injured >> farther from the hospital benefit more from OOH-ETI than those injured >> closer. METHODS: We performed a retrospective cohort analysis of trauma >> patients > 14 years old transported to two Level 1 trauma centers and >> surviving to admission from 2000 to 2003. We used probabilistically linked >> geographic data to calculate transport distance. To adjust for the nonrandom >> selection of patients for OOH-ETI, we used a propensity score based on >> clinical variables: prehospital physiology, demographics, transport mode, >> mechanism, comorbidities, Abbreviated Injury Scale head injury score >or= 3, >> Injury Severity Score, blood transfusion, and major surgery. >> Propensity-adjusted multivariable logistic regression with mode of transport >> was used to test the interaction between distance and OOH-ETI. RESULTS: >> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI had >> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence interval >> [CI] 1.33-3.18), and there was a significant interaction between distance >> and OOH-ETI (p = 0.02). Patients with shortest distances had the highest >> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was higher >> with OOH-ETI across all distances and increased for patients closest to the >> hospital. Helicopter transport was associated with improved survival. >> CONCLUSIONS: Prehospital intubation is associated with increased mortality >> among trauma patients at all distances from the hospital. Patients with the >> shortest transport distances had the greatest mortality associated with >> OOH-ETI, whereas helicopter transport was associated with improved survival. >> The event location and ensuing distance to the hospital are another factor >> to consider when instituting and modifying OOH airway protocols. >> >> E. Bledsoe, DO, FACEP >> >> >> > > > > > ************** > Play online games for FREE at Games.com! All of your favorites, > no registration required and great graphics – check it out! > (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= > http://www.games.com?ncid=emlcntusgame00000001) > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 So, Dr. Bledsoe, should we stop intubating in the field if their is an open airway? Mike mood > I posted the full article to my FTP site: > > > > http://www.mediafire.com/?zhj4niiyz3m > > > > > > From: Paramedicine [mailto:Paramedicine ] > On Behalf Of Larry Torrey > Sent: Sunday, October 26, 2008 12:28 PM > To: Paramedicine > Subject: Re: Intubation in Trauma > > > > I agree with that. > > Obviously I have not read the entire study, so I can't comment on the > details. Given only the abstract, I wonder if they would have drawn the > same conclusions if they evaluated the number of repeat set of vital > signs and how they correlate to mortality. My guess is that those who > die have been subjected to more BP measurements than those who survived. > > It's intuitive that sicker people (at least in my world) are more likely > to be intubated enroute than those who aren't so sick. It's also > intuitive that sicker people are more likely to die. Regarding > distances, I'd also argue that I perceive you to be even sicker if I've > taken the time to intubate you a short distance away from the hospital, > rather than just bag you, etc., for a mile. > > So...like vital signs assessment, is this a sx of the problem, or is > there a causal relationship? > > LT > > wegandy1938@... <mailto:wegandy1938%40aol.com> wrote: >> Is this perhaps because the intubated patients were sicker to begin >> with? >> >> What factors caused the HEMS patients to do better? >> >> GG >> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... >> <mailto:bbledsoe%40earthlink.net> writes: >> >> >>> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >>> >>> Distance impacts mortality in trauma patients with an intubation >>> attempt. >>> >>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >>> Department of Emergency Medicine, The Ohio State University, Columbus, >>> Ohio, >>> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> >>> >>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >>> associated with adverse outcomes; whether transport distance changes >>> this >>> relationship is unclear. We sought to determine whether patients >>> injured >>> farther from the hospital benefit more from OOH-ETI than those injured >>> closer. METHODS: We performed a retrospective cohort analysis of trauma >>> patients > 14 years old transported to two Level 1 trauma centers and >>> surviving to admission from 2000 to 2003. We used probabilistically >>> linked >>> geographic data to calculate transport distance. To adjust for the >>> nonrandom >>> selection of patients for OOH-ETI, we used a propensity score based on >>> clinical variables: prehospital physiology, demographics, transport >>> mode, >>> mechanism, comorbidities, Abbreviated Injury Scale head injury score >>> >or= 3, >>> Injury Severity Score, blood transfusion, and major surgery. >>> Propensity-adjusted multivariable logistic regression with mode of >>> transport >>> was used to test the interaction between distance and OOH-ETI. RESULTS: >>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI >>> had >>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence >>> interval >>> [CI] 1.33-3.18), and there was a significant interaction between >>> distance >>> and OOH-ETI (p = 0.02). Patients with shortest distances had the >>> highest >>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was >>> higher >>> with OOH-ETI across all distances and increased for patients closest to >>> the >>> hospital. Helicopter transport was associated with improved survival. >>> CONCLUSIONS: Prehospital intubation is associated with increased >>> mortality >>> among trauma patients at all distances from the hospital. Patients with >>> the >>> shortest transport distances had the greatest mortality associated with >>> OOH-ETI, whereas helicopter transport was associated with improved >>> survival. >>> The event location and ensuing distance to the hospital are another >>> factor >>> to consider when instituting and modifying OOH airway protocols. >>> >>> E. Bledsoe, DO, FACEP >>> >>> >>> >> >> >> >> >> ************** >> Play online games for FREE at Games.com! All of your favorites, >> no registration required and great graphics – check it out! >> (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= >> http://www.games.com?ncid=emlcntusgame00000001) >> >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 As much as I hate to admit it, I really feel that prehospital intubation will go away for most EMS providers. The issues are these: 1. The literature has shown that prehospital ETI (even with RSI) generally worsens outcomes. 2. Paramedics are not getting enough OR time to develop competency. 3. The alternative airways are much better. 4. ETI-related lawsuits seem to be on the increase. 5. Most EMS services cannot assure that the huge numbers of paramedics can maintain competency (which now calls for a minimum of 12 intubations a year). There are just not that many prehospital intubations to go around. 6. The prehospital ETI success rates have never been great. 7. The prehospital ETI success rate for pediatrics are horrible and there has been no benefit demonstrated in intubating kids in the prehospital setting. Pediatric ETI has been stopped in many EMS systems. I gave a presentation on this at the TCEP EMS Medical Directors Conference in September of this year and will be repeating it at EMS Today in Baltimore in March (with a concurrent article, authored with Gene Gandy, in the March issue of JEMS). I will be glad to share the Power Point if anybody is really interested. Sorry for the bad news—but that is what I ultimately see happening and happening fairly soon. BEB From: texasems-l [mailto:texasems-l ] On Behalf Of B. mood Sent: Monday, October 27, 2008 9:29 AM To: texasems-l Subject: RE: Intubation in Trauma So, Dr. Bledsoe, should we stop intubating in the field if their is an open airway? Mike mood > I posted the full article to my FTP site: > > > > http://www.mediafire.com/?zhj4niiyz3m > > > > > > From: Paramedicine <mailto:Paramedicine%40yahoogroups.com> [mailto:Paramedicine <mailto:Paramedicine%40yahoogroups.com> ] > On Behalf Of Larry Torrey > Sent: Sunday, October 26, 2008 12:28 PM > To: Paramedicine <mailto:Paramedicine%40yahoogroups.com> > Subject: Re: Intubation in Trauma > > > > I agree with that. > > Obviously I have not read the entire study, so I can't comment on the > details. Given only the abstract, I wonder if they would have drawn the > same conclusions if they evaluated the number of repeat set of vital > signs and how they correlate to mortality. My guess is that those who > die have been subjected to more BP measurements than those who survived. > > It's intuitive that sicker people (at least in my world) are more likely > to be intubated enroute than those who aren't so sick. It's also > intuitive that sicker people are more likely to die. Regarding > distances, I'd also argue that I perceive you to be even sicker if I've > taken the time to intubate you a short distance away from the hospital, > rather than just bag you, etc., for a mile. > > So...like vital signs assessment, is this a sx of the problem, or is > there a causal relationship? > > LT > > wegandy1938@... <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> wrote: >> Is this perhaps because the intubated patients were sicker to begin >> with? >> >> What factors caused the HEMS patients to do better? >> >> GG >> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... <mailto:bbledsoe%40earthlink.net> >> <mailto:bbledsoe%40earthlink.net> writes: >> >> >>> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >>> >>> Distance impacts mortality in trauma patients with an intubation >>> attempt. >>> >>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >>> Department of Emergency Medicine, The Ohio State University, Columbus, >>> Ohio, >>> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> >>> >>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >>> associated with adverse outcomes; whether transport distance changes >>> this >>> relationship is unclear. We sought to determine whether patients >>> injured >>> farther from the hospital benefit more from OOH-ETI than those injured >>> closer. METHODS: We performed a retrospective cohort analysis of trauma >>> patients > 14 years old transported to two Level 1 trauma centers and >>> surviving to admission from 2000 to 2003. We used probabilistically >>> linked >>> geographic data to calculate transport distance. To adjust for the >>> nonrandom >>> selection of patients for OOH-ETI, we used a propensity score based on >>> clinical variables: prehospital physiology, demographics, transport >>> mode, >>> mechanism, comorbidities, Abbreviated Injury Scale head injury score >>> >or= 3, >>> Injury Severity Score, blood transfusion, and major surgery. >>> Propensity-adjusted multivariable logistic regression with mode of >>> transport >>> was used to test the interaction between distance and OOH-ETI. RESULTS: >>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI >>> had >>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence >>> interval >>> [CI] 1.33-3.18), and there was a significant interaction between >>> distance >>> and OOH-ETI (p = 0.02). Patients with shortest distances had the >>> highest >>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was >>> higher >>> with OOH-ETI across all distances and increased for patients closest to >>> the >>> hospital. Helicopter transport was associated with improved survival. >>> CONCLUSIONS: Prehospital intubation is associated with increased >>> mortality >>> among trauma patients at all distances from the hospital. Patients with >>> the >>> shortest transport distances had the greatest mortality associated with >>> OOH-ETI, whereas helicopter transport was associated with improved >>> survival. >>> The event location and ensuing distance to the hospital are another >>> factor >>> to consider when instituting and modifying OOH airway protocols. >>> >>> E. Bledsoe, DO, FACEP >>> >>> >>> >> >> >> >> >> ************** >> Play online games for FREE at Games.com! All of your favorites, >> no registration required and great graphics – check it out! >> (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= >> http://www.games.com?ncid=emlcntusgame00000001) >> >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 I can definitely see the benefit of supraglottic airways, such as the King LT and the Combitube. However, I'm not seeing an alternative to endotracheal intubation in cases of laryngoedema such as airway burns and anaphylaxis. Are there other options that exist in such cases? And for what it's worth, prehospital intubation is being eliminated for first responders in Austin. Only A/TCEMS medics (ie, those on the ambulance) will be allowed to intubate under their new protocols. What's annoying to me is that the medical community has chosen to limit EMS's airway management tools rather than providing initial and continuing opportunities for airway training. It would be one thing if EMS providers were not taking advantage of training opportunities. It's a whole other thing when ORs are closed to EMS students and providers. (I know firsthand of several EMS training programs that are having to use veterinary hospitals for intubation opportunities.) -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic -Austin, Texas Re: Intubation in Trauma > > > > I agree with that. > > Obviously I have not read the entire study, so I can't comment on the > details. Given only the abstract, I wonder if they would have drawn the > same conclusions if they evaluated the number of repeat set of vital > signs and how they correlate to mortality. My guess is that those who > die have been subjected to more BP measurements than those who survived. > > It's intuitive that sicker people (at least in my world) are more likely > to be intubated enroute than those who aren't so sick. It's also > intuitive that sicker people are more likely to die. Regarding > distances, I'd also argue that I perceive you to be even sicker if I've > taken the time to intubate you a short distance away from the hospital, > rather than just bag you, etc., for a mile. > > So...like vital signs assessment, is this a sx of the problem, or is > there a causal relationship? > > LT > > wegandy1938@... <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> wrote: >> Is this perhaps because the intubated patients were sicker to begin >> with? >> >> What factors caused the HEMS patients to do better? >> >> GG >> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... <mailto:bbledsoe%40earthlink.net> >> <mailto:bbledsoe%40earthlink.net> writes: >> >> >>> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >>> >>> Distance impacts mortality in trauma patients with an intubation >>> attempt. >>> >>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >>> Department of Emergency Medicine, The Ohio State University, Columbus, >>> Ohio, >>> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> >>> >>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >>> associated with adverse outcomes; whether transport distance changes >>> this >>> relationship is unclear. We sought to determine whether patients >>> injured >>> farther from the hospital benefit more from OOH-ETI than those injured >>> closer. METHODS: We performed a retrospective cohort analysis of trauma >>> patients > 14 years old transported to two Level 1 trauma centers and >>> surviving to admission from 2000 to 2003. We used probabilistically >>> linked >>> geographic data to calculate transport distance. To adjust for the >>> nonrandom >>> selection of patients for OOH-ETI, we used a propensity score based on >>> clinical variables: prehospital physiology, demographics, transport >>> mode, >>> mechanism, comorbidities, Abbreviated Injury Scale head injury score >>> >or= 3, >>> Injury Severity Score, blood transfusion, and major surgery. >>> Propensity-adjusted multivariable logistic regression with mode of >>> transport >>> was used to test the interaction between distance and OOH-ETI. RESULTS: >>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI >>> had >>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence >>> interval >>> [CI] 1.33-3.18), and there was a significant interaction between >>> distance >>> and OOH-ETI (p = 0.02). Patients with shortest distances had the >>> highest >>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was >>> higher >>> with OOH-ETI across all distances and increased for patients closest to >>> the >>> hospital. Helicopter transport was associated with improved survival. >>> CONCLUSIONS: Prehospital intubation is associated with increased >>> mortality >>> among trauma patients at all distances from the hospital. Patients with >>> the >>> shortest transport distances had the greatest mortality associated with >>> OOH-ETI, whereas helicopter transport was associated with improved >>> survival. >>> The event location and ensuing distance to the hospital are another >>> factor >>> to consider when instituting and modifying OOH airway protocols. >>> >>> E. Bledsoe, DO, FACEP >>> >>> >>> >> >> >> >> >> ************** >> Play online games for FREE at Games.com! All of your favorites, >> no registration required and great graphics – check it out! >> (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= >> http://www.games.com?ncid=emlcntusgame00000001) >> >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 -----BEGIN PGP SIGNED MESSAGE----- Hash: SHA1 which alternative airways seen to be better?? ht Bledsoe, DO wrote: > > > As much as I hate to admit it, I really feel that prehospital intubation > will go away for most EMS providers. The issues are these: > > 1. The literature has shown that prehospital ETI (even with RSI) > generally worsens outcomes. > > 2. Paramedics are not getting enough OR time to develop competency. > > 3. The alternative airways are much better. > > 4. ETI-related lawsuits seem to be on the increase. > > 5. Most EMS services cannot assure that the huge numbers of paramedics > can maintain competency (which now calls for a minimum of 12 intubations > a year). There are just not that many prehospital intubations to go around. > > 6. The prehospital ETI success rates have never been great. > > 7. The prehospital ETI success rate for pediatrics are horrible and > there has been no benefit demonstrated in intubating kids in the > prehospital setting. Pediatric ETI has been stopped in many EMS systems. > > I gave a presentation on this at the TCEP EMS Medical Directors > Conference in September of this year and will be repeating it at EMS > Today in Baltimore in March (with a concurrent article, authored with > Gene Gandy, in the March issue of JEMS). I will be glad to share the > Power Point if anybody is really interested. > > Sorry for the bad news—but that is what I ultimately see happening and > happening fairly soon. > > BEB > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > [mailto:texasems-l > <mailto:texasems-l%40yahoogroups.com>] On Behalf Of B. mood > Sent: Monday, October 27, 2008 9:29 AM > To: texasems-l <mailto:texasems-l%40yahoogroups.com> > Subject: RE: Intubation in Trauma > > So, Dr. Bledsoe, > > should we stop intubating in the field if their is an open airway? > > Mike mood >> I posted the full article to my FTP site: >> >> >> >> http://www.mediafire.com/?zhj4niiyz3m > <http://www.mediafire.com/?zhj4niiyz3m> >> >> >> >> >> >> From: Paramedicine > <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > [mailto:Paramedicine > <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> ] >> On Behalf Of Larry Torrey >> Sent: Sunday, October 26, 2008 12:28 PM >> To: Paramedicine > <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> >> Subject: Re: Intubation in Trauma >> >> >> >> I agree with that. >> >> Obviously I have not read the entire study, so I can't comment on the >> details. Given only the abstract, I wonder if they would have drawn the >> same conclusions if they evaluated the number of repeat set of vital >> signs and how they correlate to mortality. My guess is that those who >> die have been subjected to more BP measurements than those who survived. >> >> It's intuitive that sicker people (at least in my world) are more likely >> to be intubated enroute than those who aren't so sick. It's also >> intuitive that sicker people are more likely to die. Regarding >> distances, I'd also argue that I perceive you to be even sicker if I've >> taken the time to intubate you a short distance away from the hospital, >> rather than just bag you, etc., for a mile. >> >> So...like vital signs assessment, is this a sx of the problem, or is >> there a causal relationship? >> >> LT >> >> wegandy1938@... <mailto:wegandy1938%40aol.com> > <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> wrote: >>> Is this perhaps because the intubated patients were sicker to begin >>> with? >>> >>> What factors caused the HEMS patients to do better? >>> >>> GG >>> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... > <mailto:bbledsoe%40earthlink.net> <mailto:bbledsoe%40earthlink.net> >>> <mailto:bbledsoe%40earthlink.net> writes: >>> >>> >>>> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >>>> >>>> Distance impacts mortality in trauma patients with an intubation >>>> attempt. >>>> >>>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >>>> Department of Emergency Medicine, The Ohio State University, Columbus, >>>> Ohio, >>>> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> > <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> >>>> >>>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >>>> associated with adverse outcomes; whether transport distance changes >>>> this >>>> relationship is unclear. We sought to determine whether patients >>>> injured >>>> farther from the hospital benefit more from OOH-ETI than those injured >>>> closer. METHODS: We performed a retrospective cohort analysis of trauma >>>> patients > 14 years old transported to two Level 1 trauma centers and >>>> surviving to admission from 2000 to 2003. We used probabilistically >>>> linked >>>> geographic data to calculate transport distance. To adjust for the >>>> nonrandom >>>> selection of patients for OOH-ETI, we used a propensity score based on >>>> clinical variables: prehospital physiology, demographics, transport >>>> mode, >>>> mechanism, comorbidities, Abbreviated Injury Scale head injury score >>>> >or= 3, >>>> Injury Severity Score, blood transfusion, and major surgery. >>>> Propensity-adjusted multivariable logistic regression with mode of >>>> transport >>>> was used to test the interaction between distance and OOH-ETI. RESULTS: >>>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI >>>> had >>>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence >>>> interval >>>> [CI] 1.33-3.18), and there was a significant interaction between >>>> distance >>>> and OOH-ETI (p = 0.02). Patients with shortest distances had the >>>> highest >>>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was >>>> higher >>>> with OOH-ETI across all distances and increased for patients closest to >>>> the >>>> hospital. Helicopter transport was associated with improved survival. >>>> CONCLUSIONS: Prehospital intubation is associated with increased >>>> mortality >>>> among trauma patients at all distances from the hospital. Patients with >>>> the >>>> shortest transport distances had the greatest mortality associated with >>>> OOH-ETI, whereas helicopter transport was associated with improved >>>> survival. >>>> The event location and ensuing distance to the hospital are another >>>> factor >>>> to consider when instituting and modifying OOH airway protocols. >>>> >>>> E. Bledsoe, DO, FACEP >>>> >>>> >>>> >>> >>> >>> >>> >>> ************** >>> Play online games for FREE at Games.com! All of your favorites, >>> no registration required and great graphics – check it out! >>> > (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= > <http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir=> >>> http://www.games.com?ncid=emlcntusgame00000001 > <http://www.games.com?ncid=emlcntusgame00000001>) >>> >>> >>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 Agreed. Part of it comes down to the fact that many general anesthesia cases are now done with LMAs. With fewer ETI opportunities, EMS personnel (at the bottom of the ETI pecking order in the OR) are not getting the opportunity. There are paramedic programs graduating medics who have never done a successful intubation in a human. Also, now we have to get family permission to practice on the recently dead cadavers—further limiting opportunities. I have intubated dogs, cats and ferrets. They are not an adequate substitute for human tissue practice. BEB From: texasems-l [mailto:texasems-l ] On Behalf Of ExLngHrn@... Sent: Monday, October 27, 2008 10:05 AM To: texasems-l Subject: Re: Intubation in Trauma I can definitely see the benefit of supraglottic airways, such as the King LT and the Combitube. However, I'm not seeing an alternative to endotracheal intubation in cases of laryngoedema such as airway burns and anaphylaxis. Are there other options that exist in such cases? And for what it's worth, prehospital intubation is being eliminated for first responders in Austin. Only A/TCEMS medics (ie, those on the ambulance) will be allowed to intubate under their new protocols. What's annoying to me is that the medical community has chosen to limit EMS's airway management tools rather than providing initial and continuing opportunities for airway training. It would be one thing if EMS providers were not taking advantage of training opportunities. It's a whole other thing when ORs are closed to EMS students and providers. (I know firsthand of several EMS training programs that are having to use veterinary hospitals for intubation opportunities.) -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic -Austin, Texas Re: Intubation in Trauma > > > > I agree with that. > > Obviously I have not read the entire study, so I can't comment on the > details. Given only the abstract, I wonder if they would have drawn the > same conclusions if they evaluated the number of repeat set of vital > signs and how they correlate to mortality. My guess is that those who > die have been subjected to more BP measurements than those who survived. > > It's intuitive that sicker people (at least in my world) are more likely > to be intubated enroute than those who aren't so sick. It's also > intuitive that sicker people are more likely to die. Regarding > distances, I'd also argue that I perceive you to be even sicker if I've > taken the time to intubate you a short distance away from the hospital, > rather than just bag you, etc., for a mile. > > So...like vital signs assessment, is this a sx of the problem, or is > there a causal relationship? > > LT > > wegandy1938@... <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> wrote: >> Is this perhaps because the intubated patients were sicker to begin >> with? >> >> What factors caused the HEMS patients to do better? >> >> GG >> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... <mailto:bbledsoe%40earthlink.net> <mailto:bbledsoe%40earthlink.net> >> <mailto:bbledsoe%40earthlink.net> writes: >> >> >>> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >>> >>> Distance impacts mortality in trauma patients with an intubation >>> attempt. >>> >>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >>> Department of Emergency Medicine, The Ohio State University, Columbus, >>> Ohio, >>> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> >>> >>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >>> associated with adverse outcomes; whether transport distance changes >>> this >>> relationship is unclear. We sought to determine whether patients >>> injured >>> farther from the hospital benefit more from OOH-ETI than those injured >>> closer. METHODS: We performed a retrospective cohort analysis of trauma >>> patients > 14 years old transported to two Level 1 trauma centers and >>> surviving to admission from 2000 to 2003. We used probabilistically >>> linked >>> geographic data to calculate transport distance. To adjust for the >>> nonrandom >>> selection of patients for OOH-ETI, we used a propensity score based on >>> clinical variables: prehospital physiology, demographics, transport >>> mode, >>> mechanism, comorbidities, Abbreviated Injury Scale head injury score >>> >or= 3, >>> Injury Severity Score, blood transfusion, and major surgery. >>> Propensity-adjusted multivariable logistic regression with mode of >>> transport >>> was used to test the interaction between distance and OOH-ETI. RESULTS: >>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI >>> had >>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence >>> interval >>> [CI] 1.33-3.18), and there was a significant interaction between >>> distance >>> and OOH-ETI (p = 0.02). Patients with shortest distances had the >>> highest >>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was >>> higher >>> with OOH-ETI across all distances and increased for patients closest to >>> the >>> hospital. Helicopter transport was associated with improved survival. >>> CONCLUSIONS: Prehospital intubation is associated with increased >>> mortality >>> among trauma patients at all distances from the hospital. Patients with >>> the >>> shortest transport distances had the greatest mortality associated with >>> OOH-ETI, whereas helicopter transport was associated with improved >>> survival. >>> The event location and ensuing distance to the hospital are another >>> factor >>> to consider when instituting and modifying OOH airway protocols. >>> >>> E. Bledsoe, DO, FACEP >>> >>> >>> >> >> >> >> >> ************** >> Play online games for FREE at Games.com! All of your favorites, >> no registration required and great graphics – check it out! >> (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= >> http://www.games.com?ncid=emlcntusgame00000001) >> >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 I’ll pass that to Gene. I think the King is way up there. BEB From: texasems-l [mailto:texasems-l ] On Behalf Of H.T. Fillingim Sent: Monday, October 27, 2008 10:16 AM To: texasems-l Subject: Re: Intubation in Trauma -----BEGIN PGP SIGNED MESSAGE----- Hash: SHA1 which alternative airways seen to be better?? ht Bledsoe, DO wrote: > > > As much as I hate to admit it, I really feel that prehospital intubation > will go away for most EMS providers. The issues are these: > > 1. The literature has shown that prehospital ETI (even with RSI) > generally worsens outcomes. > > 2. Paramedics are not getting enough OR time to develop competency. > > 3. The alternative airways are much better. > > 4. ETI-related lawsuits seem to be on the increase. > > 5. Most EMS services cannot assure that the huge numbers of paramedics > can maintain competency (which now calls for a minimum of 12 intubations > a year). There are just not that many prehospital intubations to go around. > > 6. The prehospital ETI success rates have never been great. > > 7. The prehospital ETI success rate for pediatrics are horrible and > there has been no benefit demonstrated in intubating kids in the > prehospital setting. Pediatric ETI has been stopped in many EMS systems. > > I gave a presentation on this at the TCEP EMS Medical Directors > Conference in September of this year and will be repeating it at EMS > Today in Baltimore in March (with a concurrent article, authored with > Gene Gandy, in the March issue of JEMS). I will be glad to share the > Power Point if anybody is really interested. > > Sorry for the bad news—but that is what I ultimately see happening and > happening fairly soon. > > BEB > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> <mailto:texasems-l%40yahoogroups.com> > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com>] On Behalf Of B. mood > Sent: Monday, October 27, 2008 9:29 AM > To: texasems-l <mailto:texasems-l%40yahoogroups.com> <mailto:texasems-l%40yahoogroups.com> > Subject: RE: Intubation in Trauma > > So, Dr. Bledsoe, > > should we stop intubating in the field if their is an open airway? > > Mike mood >> I posted the full article to my FTP site: >> >> >> >> http://www.mediafire.com/?zhj4niiyz3m > <http://www.mediafire.com/?zhj4niiyz3m> >> >> >> >> >> >> From: Paramedicine <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > [mailto:Paramedicine <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> ] >> On Behalf Of Larry Torrey >> Sent: Sunday, October 26, 2008 12:28 PM >> To: Paramedicine <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> >> Subject: Re: Intubation in Trauma >> >> >> >> I agree with that. >> >> Obviously I have not read the entire study, so I can't comment on the >> details. Given only the abstract, I wonder if they would have drawn the >> same conclusions if they evaluated the number of repeat set of vital >> signs and how they correlate to mortality. My guess is that those who >> die have been subjected to more BP measurements than those who survived. >> >> It's intuitive that sicker people (at least in my world) are more likely >> to be intubated enroute than those who aren't so sick. It's also >> intuitive that sicker people are more likely to die. Regarding >> distances, I'd also argue that I perceive you to be even sicker if I've >> taken the time to intubate you a short distance away from the hospital, >> rather than just bag you, etc., for a mile. >> >> So...like vital signs assessment, is this a sx of the problem, or is >> there a causal relationship? >> >> LT >> >> wegandy1938@... <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> > <mailto:wegandy1938%40aol.com> <mailto:wegandy1938%40aol.com> wrote: >>> Is this perhaps because the intubated patients were sicker to begin >>> with? >>> >>> What factors caused the HEMS patients to do better? >>> >>> GG >>> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... <mailto:bbledsoe%40earthlink.net> > <mailto:bbledsoe%40earthlink.net> <mailto:bbledsoe%40earthlink.net> >>> <mailto:bbledsoe%40earthlink.net> writes: >>> >>> >>>> Prehosp Emerg Care. 2008 Oct-Dec;12(4)Prehosp >>>> >>>> Distance impacts mortality in trauma patients with an intubation >>>> attempt. >>>> >>>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. >>>> Department of Emergency Medicine, The Ohio State University, Columbus, >>>> Ohio, >>>> USA. michael.cudnik@... <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> > <mailto:michael.cudnik%40michael.c> <mailto:michael.cudnik%40michael.c> >>>> >>>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been >>>> associated with adverse outcomes; whether transport distance changes >>>> this >>>> relationship is unclear. We sought to determine whether patients >>>> injured >>>> farther from the hospital benefit more from OOH-ETI than those injured >>>> closer. METHODS: We performed a retrospective cohort analysis of trauma >>>> patients > 14 years old transported to two Level 1 trauma centers and >>>> surviving to admission from 2000 to 2003. We used probabilistically >>>> linked >>>> geographic data to calculate transport distance. To adjust for the >>>> nonrandom >>>> selection of patients for OOH-ETI, we used a propensity score based on >>>> clinical variables: prehospital physiology, demographics, transport >>>> mode, >>>> mechanism, comorbidities, Abbreviated Injury Scale head injury score >>>> >or= 3, >>>> Injury Severity Score, blood transfusion, and major surgery. >>>> Propensity-adjusted multivariable logistic regression with mode of >>>> transport >>>> was used to test the interaction between distance and OOH-ETI. RESULTS: >>>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI >>>> had >>>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence >>>> interval >>>> [CI] 1.33-3.18), and there was a significant interaction between >>>> distance >>>> and OOH-ETI (p = 0.02). Patients with shortest distances had the >>>> highest >>>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was >>>> higher >>>> with OOH-ETI across all distances and increased for patients closest to >>>> the >>>> hospital. Helicopter transport was associated with improved survival. >>>> CONCLUSIONS: Prehospital intubation is associated with increased >>>> mortality >>>> among trauma patients at all distances from the hospital. Patients with >>>> the >>>> shortest transport distances had the greatest mortality associated with >>>> OOH-ETI, whereas helicopter transport was associated with improved >>>> survival. >>>> The event location and ensuing distance to the hospital are another >>>> factor >>>> to consider when instituting and modifying OOH airway protocols. >>>> >>>> E. Bledsoe, DO, FACEP >>>> >>>> >>>> >>> >>> >>> >>> >>> ************** >>> Play online games for FREE at Games.com! All of your favorites, >>> no registration required and great graphics – check it out! >>> > (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= > <http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir=> >>> http://www.games.com?ncid=emlcntusgame00000001 > <http://www.games.com?ncid=emlcntusgame00000001>) >>> >>> >>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 Dr. Bledsoe, Not to be argumentative, but just for clarification, I have a couple questions: > 1. The literature has shown that prehospital ETI (even with RSI) generally > worsens outcomes. Does the actual act of establishing an airway have a proven cause-effect worsening, or is it more related to other factors such as time, failure, or generally sicker patients? > 3. The alternative airways are much better. Do you mean better as in 'better than they used to be,' or better as in 'better than ETI'? And by better, do you mean more effective in establishing and maintaining an airway, or do you mean easier to perform? Or something else maybe? And, if the success rate were improved to mirror that of in-hospital, physician performed ETI, would any of these factors still be significant? Thanks, Rob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 Rob: Good questions. It appears to be a cause and effect complicated by hypoventilation, hyperventilation and multiple attempts. 4-5 studies to date(all over the US) are showing that head-injured patients and others do worse when paramedics intubate them (e.g., higher mortality). These studies look at injury severity and equalize other variables. In terms of kids, several studies have shown kids ventilated with BVM do just as well. Thus, if ETI provides no advantage, and one child somewhere in the US gets a tube in the esophagus, then is it worth it? The alternative airways are “better than they used to be†and approaching the ETI in quality. Still, you cannot put a patient on a vent long-term with an alternative airway. For the most part, studies of ED physician performance is better than prehospital (we get more practice). Interestingly, one study looked at senior attending who do not intubate often and found their intubation skills still strong. It comes down to mastering the 5 levels of skill development. BEB From: texasems-l [mailto:texasems-l ] On Behalf Of rob.davis@... Sent: Monday, October 27, 2008 11:26 AM To: texasems-l Subject: RE: Intubation in Trauma Dr. Bledsoe, Not to be argumentative, but just for clarification, I have a couple questions: > 1. The literature has shown that prehospital ETI (even with RSI) generally > worsens outcomes. Does the actual act of establishing an airway have a proven cause-effect worsening, or is it more related to other factors such as time, failure, or generally sicker patients? > 3. The alternative airways are much better. Do you mean better as in 'better than they used to be,' or better as in 'better than ETI'? And by better, do you mean more effective in establishing and maintaining an airway, or do you mean easier to perform? Or something else maybe? And, if the success rate were improved to mirror that of in-hospital, physician performed ETI, would any of these factors still be significant? Thanks, Rob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 I would say the King LT and the EasyTube. However, there are some dynamite new fiberoptic and video-type laryngoscopes now on the market that may well have an impact. The AirTraq is the most economically feasible, $80.00 per disposable unit, and it does a great job. We have intubated very difficult cadavers with it without difficulty, and it's coming out with a pedi version and a nasotracheal version soon. Also the GlideScope Ranger is available. It requires a larger initial investment, but it's also within the grasp of most services. These are devices that give you a look at the cords in just about everybody. Further, there are blades out there such as the ViewMax that have been available for years that folks are not using, which improve ETI greatly. So I see great changes coming, and elimination of traditional ETI is probably one of them, but with the progress in technology, all may not be lost. However, services need to get off their butts and look into reality and make changes based upon the current situation. There are still services that don't carry bougies, and there's no excuse for that. Bougies will improve results across the board. Stay tuned. GG > > I’ll pass that to Gene. I think the King is way up there. > > BEB > > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of H.T. Fillingim > Sent: Monday, October 27, 2008 10:16 AM > To: texasems-l@yahoogrotexasem > Subject: Re: Intubation in Trauma > > -----BEGIN PGP SIGNED MESSAGE----- > Hash: SHA1 > > which alternative airways seen to be better?? ht > > Bledsoe, DO wrote: > > > > > > As much as I hate to admit it, I really feel that prehospital intubation > > will go away for most EMS providers. The issues are these: > > > > 1. The literature has shown that prehospital ETI (even with RSI) > > generally worsens outcomes. > > > > 2. Paramedics are not getting enough OR time to develop competency. > > > > 3. The alternative airways are much better. > > > > 4. ETI-related lawsuits seem to be on the increase. > > > > 5. Most EMS services cannot assure that the huge numbers of paramedics > > can maintain competency (which now calls for a minimum of 12 intubations > > a year). There are just not that many prehospital intubations to go > around. > > > > 6. The prehospital ETI success rates have never been great. > > > > 7. The prehospital ETI success rate for pediatrics are horrible and > > there has been no benefit demonstrated in intubating kids in the > > prehospital setting. Pediatric ETI has been stopped in many EMS systems. > > > > I gave a presentation on this at the TCEP EMS Medical Directors > > Conference in September of this year and will be repeating it at EMS > > Today in Baltimore in March (with a concurrent article, authored with > > Gene Gandy, in the March issue of JEMS). I will be glad to share the > > Power Point if anybody is really interested. > > > > Sorry for the bad news—but that is what I ultimately see happening and > > happening fairly soon. > > > > BEB > > > > From: texasems-l@yahoogrotexasem <mailto:texasems-mailto:texasems-mai> < > mailto:texasems-mailto:texasems-mai> > > [mailto:texasems-l@yahoogrotexasem <mailto:texasems-mailto:texasems-mai> > > <mailto:texasems-mailto:texasems-mai>] On Behalf Of B. mood > > Sent: Monday, October 27, 2008 9:29 AM > > To: texasems-l@yahoogrotexasem <mailto:texasems-mailto:texasems-mai> < > mailto:texasems-mailto:texasems-mai> > > Subject: RE: Intubation in Trauma > > > > So, Dr. Bledsoe, > > > > should we stop intubating in the field if their is an open airway? > > > > Mike mood > >> I posted the full article to my FTP site: > >> > >> > >> > >> http://www.mediafirhttp://www.mediaht > > <http://www.mediafirhttp://www.mediaht> > >> > >> > >> > >> > >> > >> From: Paramedicine@ParamedicinePar <mailto:Paramedicinmailto:Paramedicmai> > > > <mailto:Paramedicinmailto:Paramedicmai> > > <mailto:Paramedicinmailto:Paramedicmai> > > [mailto:Paramedicine@ParamedicinePar < > mailto:Paramedicinmailto:Paramedicmai> > > <mailto:Paramedicinmailto:Paramedicmai> > > <mailto:Paramedicinmailto:Paramedicmai> ] > >> On Behalf Of Larry Torrey > >> Sent: Sunday, October 26, 2008 12:28 PM > >> To: Paramedicine@ParamedicinePar <mailto:Paramedicinmailto:Paramedicmai> > > <mailto:Paramedicinmailto:Paramedicmai> > > <mailto:Paramedicinmailto:Paramedicmai> > >> Subject: Re: Intubation in Trauma > >> > >> > >> > >> I agree with that. > >> > >> Obviously I have not read the entire study, so I can't comment on the > >> details. Given only the abstract, I wonder if they would have drawn the > >> same conclusions if they evaluated the number of repeat set of vital > >> signs and how they correlate to mortality. My guess is that those who > >> die have been subjected to more BP measurements than those who survived. > >> > >> It's intuitive that sicker people (at least in my world) are more likely > >> to be intubated enroute than those who aren't so sick. It's also > >> intuitive that sicker people are more likely to die. Regarding > >> distances, I'd also argue that I perceive you to be even sicker if I've > >> taken the time to intubate you a short distance away from the hospital, > >> rather than just bag you, etc., for a mile. > >> > >> So...like vital signs assessment, is this a sx of the problem, or is > >> there a causal relationship? > >> > >> LT > >> > >> wegandy1938@wegandy <mailto:wegandy1938mailto:weg> < > mailto:wegandy1938mailto:weg> > > <mailto:wegandy1938mailto:weg> <mailto:wegandy1938mailto:weg> wrote: > >>> Is this perhaps because the intubated patients were sicker to begin > >>> with? > >>> > >>> What factors caused the HEMS patients to do better? > >>> > >>> GG > >>> In a message dated 10/25/08 10:58:59 AM, bbledsoe@... < > mailto:bbledsoe%mailto:bbledmai> > > <mailto:bbledsoe%mailto:bbledmai> <mailto:bbledsoe%mailto:bbledmai> > >>> <mailto:bbledsoe%mailto:bbledmai> writes: > >>> > >>> > >>>> Prehosp Emerg Care. 2008 Oct-Dec;12(4) Prehos > >>>> > >>>> Distance impacts mortality in trauma patients with an intubation > >>>> attempt. > >>>> > >>>> Cudnik MT, Newgard CD, Wang H, Bangs C, Herrington R 4th. > >>>> Department of Emergency Medicine, The Ohio State University, Columbus, > >>>> Ohio, > >>>> USA. michael.cudnik@... <mailto:michael.mailto:michael.ma> < > mailto:michael.mailto:michael.ma> > > <mailto:michael.mailto:michael.ma> <mailto:michael.mailto:michael.ma> > >>>> > >>>> OBJECTIVE: Out-of-hospital endotracheal intubation (OOH-ETI) has been > >>>> associated with adverse outcomes; whether transport distance changes > >>>> this > >>>> relationship is unclear. We sought to determine whether patients > >>>> injured > >>>> farther from the hospital benefit more from OOH-ETI than those injured > >>>> closer. METHODS: We performed a retrospective cohort analysis of trauma > >>>> patients > 14 years old transported to two Level 1 trauma centers and > >>>> surviving to admission from 2000 to 2003. We used probabilistically > >>>> linked > >>>> geographic data to calculate transport distance. To adjust for the > >>>> nonrandom > >>>> selection of patients for OOH-ETI, we used a propensity score based on > >>>> clinical variables: prehospital physiology, demographics, transport > >>>> mode, > >>>> mechanism, comorbidities, Abbreviated Injury Scale head injury score > >>>> >or= 3, > >>>> Injury Severity Score, blood transfusion, and major surgery. > >>>> Propensity-adjusted multivariable logistic regression with mode of > >>>> transport > >>>> was used to test the interaction between distance and OOH-ETI. RESULTS: > >>>> 8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI > >>>> had > >>>> higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence > >>>> interval > >>>> [CI] 1.33-3.18), and there was a significant interaction between > >>>> distance > >>>> and OOH-ETI (p = 0.02). Patients with shortest distances had the > >>>> highest > >>>> mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was > >>>> higher > >>>> with OOH-ETI across all distances and increased for patients closest to > >>>> the > >>>> hospital. Helicopter transport was associated with improved survival. > >>>> CONCLUSIONS: Prehospital intubation is associated with increased > >>>> mortality > >>>> among trauma patients at all distances from the hospital. Patients with > >>>> the > >>>> shortest transport distances had the greatest mortality associated with > >>>> OOH-ETI, whereas helicopter transport was associated with improved > >>>> survival. > >>>> The event location and ensuing distance to the hospital are another > >>>> factor > >>>> to consider when instituting and modifying OOH airway protocols. > >>>> > >>>> E. Bledsoe, DO, FACEP > >>>> > >>>> > >>>> > >>> > >>> > >>> > >>> > >>> ************ * > >>> Play online games for FREE at Games.com! All of your favorites, > >>> no registration required and great graphics – check it out! > >>> > > (http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr. > > <http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.> > >>> http://www.games.http://wwhttp://www.gameshttp > > <http://www.games.http://wwhttp://www.gameshttp>) > >>> > >>> > >>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 27, 2008 Report Share Posted October 27, 2008 On Monday, October 27, 2008 14:52, " Bledsoe, DO " said: > > Thus, if ETI provides no advantage, and one child somewhere in the US > gets a tube in the esophagus, then is it worth it? I agree that this is certainly a valid question. Our technical success rate is dismal. But that is only half of the problem. Even if that is significantly improved, our clinical judgement regarding when the procedure is appropriate and beneficial remains in question. Gene makes the point that I was considering, which is that ETI success rates can be improved, and that improvements are potentially on the immediate horizon. And the question of judgement could be successfully addressed in the same manner as every other question facing EMS today, which is education. Unfortunately, the usual suspects, who continue to whine that " we don't need all that book learnin " will forever prevent paramedic education from making that quantum leap. So yes, kiss ETI goodbye, and thank a volunteer fireman. Rob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 While understanding the problem, at what point will the legal system get " caught up " with current research and teaching (I can only imagine it will be years)? Any current textbook mentions ETI numerous times as the definitive treatment and recommends it. Until we have a major shift in our educational process, it seems that there will be significant liability for those who do not intubate. This will be a major point in our professions career development. Will it fall back on Medical Direction? What will the Standard of Care be? When will it change? I can't imagine at this point answering the question of why no intubation attempt occurred on a patient unable to maintain an airway, even though the medic may have chosen another option (which would be held as inferior to ETI in the court of law). We're in for an interesting few years. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 To date I do not know of any Police Officer, Soldier and add to that a concealed handgun carrier who got to pull the trigger at live person under the stress that is a live shooting. “Training” and more “Training” on inanimate targets is all they get until the fateful day comes that are looking down the barrel of gun pointed at them by a real live human being; then and only then does the real life split second decision they are to make have to be made. Most, depending on training have very good outcomes; others have a less than desirable outcome, much like airway managment. I want to pose the following; 1. Training will always be the Medics best way to prepare for ETTI; How they train will dictate outcomes and performance. In a article several years ago Mckay referenced “H.I.T.” hormonal induced tachycardia- in short, elevated heart rates with poor training caused Catastrophic Performance Deterioration. The way we train manifests outcomes and as educators we fall short a lot of the time in really pushing our students to the limits. 2. I will concede that too much time is spent on some scenes trying to manage airways, when a King LT or King LTD could be used and then transitioned at the ER. (Especially since you can use a vent with it) But, no “glotic” only device will totally protect against all aspirations and there will be times that a ETT is the ideal airway device, or the only one that will work based on the trauma at hand. The problem I see in the future, is that if we take away ETT intubations except for those certain times, what will the success rate be that one or two times. This sets the Medic up for failure on multiple fronts. 3. I think the part of the study in 2000 – 2003 I have seen, left out critical data on weather it was time on scene or failed to recognize the unsuccessful ETT attempt, or as stated by many of you, the patient was going to die anyway. This is where services who perform advanced airway management of any kind, as well as RSI should be using Quantitative/Qualitative ETCo2 on any advanced airway management. ( that’s all that needs to be said there) To sum it up; it doesn’t matter if you use live patients in the OR, or Mannequins in the classroom, if you fail to put students and newwe practicing Medics in situations that cause them to work in a stressful, elevated environment, when the time comes they will have little to no chance at success. Those who have been at this for a while have had their share of success and failure and will have at least a few experiences to draw upon. JMO W Subject: RE: Intubation in Trauma To: texasems-l Date: Monday, October 27, 2008, 8:16 PM On Monday, October 27, 2008 14:52, " Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) net> said: > > Thus, if ETI provides no advantage, and one child somewhere in the US > gets a tube in the esophagus, then is it worth it? I agree that this is certainly a valid question. Our technical success rate is dismal. But that is only half of the problem. Even if that is significantly improved, our clinical judgement regarding when the procedure is appropriate and beneficial remains in question. Gene makes the point that I was considering, which is that ETI success rates can be improved, and that improvements are potentially on the immediate horizon. And the question of judgement could be successfully addressed in the same manner as every other question facing EMS today, which is education. Unfortunately, the usual suspects, who continue to whine that " we don't need all that book learnin " will forever prevent paramedic education from making that quantum leap. So yes, kiss ETI goodbye, and thank a volunteer fireman. Rob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 Way to go Chris. I fully agree and I am not going to tell yall why. A hint would be that you can teach a monkey to intubate. Practice Put the round tube in the little black hole. If you need to intubate then your patient isn't the best suspect for a good outcome in the first place. I guess I did tell you anyway. No study performed just 35 years of running calls. Henry RE: Intubation in Trauma To: texasems-l Date: Monday, October 27, 2008, 8:16 PM On Monday, October 27, 2008 14:52, " Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) net> said: > > Thus, if ETI provides no advantage, and one child somewhere in the US > gets a tube in the esophagus, then is it worth it? I agree that this is certainly a valid question. Our technical success rate is dismal. But that is only half of the problem. Even if that is significantly improved, our clinical judgement regarding when the procedure is appropriate and beneficial remains in question. Gene makes the point that I was considering, which is that ETI success rates can be improved, and that improvements are potentially on the immediate horizon. And the question of judgement could be successfully addressed in the same manner as every other question facing EMS today, which is education. Unfortunately, the usual suspects, who continue to whine that " we don't need all that book learnin " will forever prevent paramedic education from making that quantum leap. So yes, kiss ETI goodbye, and thank a volunteer fireman. Rob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 Sigh. I hate to write the same things over and over, but I have to try to correct some of the ideas folks have about the legal process. " dlacx " wrote: ....... >>> I can't imagine at this point answering the question of why no intubation attempt occurred on a patient unable to maintain an airway, even though the medic may have chosen another option (which would be held as inferior to ETI in the court of law). <<< Let's try to put that statement into the context of what happens in a trial. The attorneys have wide latitude in civil cases to question witnesses about what happened, why they did this or that, and what all the circumstances were. As I have said before, the facts drive the case. All the factual evidence gets presented, then it is the experts who express their opinions of what the applicable standard of care was. It is the jury that determines that fact. So the last part of the sentence I quote " (which would be held as inferior to ETI in the court of law) " is misleading. First, when one uses the word " held " in conjunction with a court proceeding, that generally means that the Court makes a ruling or " holding. " So in an airway case, unless the case is being tried before a judge without a jury, the judge would not make a holding that X was " inferior to ETI. " That is purely a question for the jury, based upon the facts of the case as they are brought out by the lawyers through the testimony of the witnesses. The question the jury will answer is whether or not what was done was reasonable under the circumstances, so if it believes that use of an alternative airway was reasonable, end of case. Whatever any textbook or set of standards says is subject to question and subject to explanation. In fact, I hate to use the word " standards " when referring to what texts and AHA and so forth say, because they are really only guidelines. The ultimate jury question in a negligence case is always what was reasonable under the circumstances. So typically one expert will testify that since the patient aspirated, an ETI would have prevented that, and it should have been done. The other expert might testify that since the most pressing question at the time was getting the patient ventilated in order to immediately save his life, the choice of an alternative airway was reasonable under the circumstances. See what I mean? There are no absolutes. It's all subject to proof, and a jury of our " peers " --sometimes amusingly referred to as 6 people who weren't smart enough to get out of jury duty, decides. I hope this helps. Do what's reasonable and prudent under the circumstances, folks, and you'll satisfy the standard of care. That is, if you have documented it, don't come off as being a fool or an ass to the jurors, don't have red hair and the jurors don't like red hair, the plaintiff's expert makes your expert look like a fool, and so forth. Now, isn't that simple? Gene G. The last statement In a message dated 10/28/08 12:43:26 PM, kenneth.navarro@... writes: > > " dlacx " wrote: >>> Any current textbook mentions ETI > numerous times as the definitive treatment and recommends it. > > The ILCOR guidelines and the American Heart Association recommend > endotracheal intubation only with many caveats. > > > > What evidence would the court use to make that decision? The > preponderance of the evidence (I have seen) suggests the opposite. > > Kenny Navarro > > ************** Play online games for FREE at Games.com! All of your favorites, no registration required and great graphics – check it out! (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= http://www.games.com?ncid=emlcntusgame00000001) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 " dlacx " wrote: >>> Any current textbook mentions ETI numerous times as the definitive treatment and recommends it. The ILCOR guidelines and the American Heart Association recommend endotracheal intubation only with many caveats. >>> I can't imagine at this point answering the question of why no intubation attempt occurred on a patient unable to maintain an airway, even though the medic may have chosen another option (which would be held as inferior to ETI in the court of law). <<< What evidence would the court use to make that decision? The preponderance of the evidence (I have seen) suggests the opposite. Kenny Navarro Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 Just as a friendly reminder/lesson, the question as to standard of care is a question of fact, thus, as I jokingly say, the standard of care is defined by twelve people who couldn't get out of jury duty. All the more reason to avoid a lawsuit in the first place. In my opinion, continuing endotracheal intubation requires significant training and a quality improvement process.? Personally, I believe that, in some cases, there is no substitute for an ET tube, such as anaphylaxsis or airway burns.? (IE, when airway compromise exists below the glottic opening.) We need to quit educating EMS students that any one form of ventilatory support is the " gold standard. " The gold standard has always been and remains sufficient ventilation to support perfusion and cellular respiration.? In most cardiac arrest scenarios, though, I'd hazard a supposition that the patient would benefit more from good CPR and electricity than an ET tube.? In other words, get the King, LMA, Combitube, or OPA in place, quit messing with the tube, and start CPR and/or defibrillation. Also, if you are intubating without a full plethora of support mechanisms (bougie, waveform capnography, supraglottic airway, etc), you are in severe risk of a failed intubation. -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic Re: Intubation in Trauma " dlacx " wrote: >>> Any current textbook mentions ETI numerous times as the definitive treatment and recommends it. The ILCOR guidelines and the American Heart Association recommend endotracheal intubation only with many caveats. >>> I can't imagine at this point answering the question of why no intubation attempt occurred on a patient unable to maintain an airway, even though the medic may have chosen another option (which would be held as inferior to ETI in the court of law). <<< What evidence would the court use to make that decision? The preponderance of the evidence (I have seen) suggests the opposite. Kenny Navarro Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 On Tuesday, October 28, 2008 19:03, " Bledsoe, DO " said: > > Should patient assessment not be the most important prehospital skill? Bingo. That's the number one point I have been trying to make for years now. And it further validates the theory that we need to drag EMS education, kicking and screaming, away from this idea of paramedical practice being skills-based, and divided into ALS and BLS categories. The better your assessment is, the less the chance is that you will need advanced skills. Rob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 28, 2008 Report Share Posted October 28, 2008 Bledsoe for President! Rob for Vice-President! GG > > On Tuesday, October 28, 2008 19:03, " Bledsoe, DO " < > bbledsoe@...> said: > > > > Should patient assessment not be the most important prehospital skill? > > Bingo. That's the number one point I have been trying to make for years now. > And it further validates the theory that we need to drag EMS education, > kicking and screaming, away from this idea of paramedical practice being > skills-based, and divided into ALS and BLS categories. > > The better your assessment is, the less the chance is that you will need > advanced skills. > > Rob > > ************** Play online games for FREE at Games.com! All of your favorites, no registration required and great graphics – check it out! (http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir= http://www.games.com?ncid=emlcntusgame00000001) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 or, as Grayson, Kim on, and I have been teaching for years, " Paramedics may save lives, but Basics save Paramedics.... " ck S. Krin, DO FAAFP In a message dated 10/28/2008 20:54:46 Central Daylight Time, rob.davis@... writes: The better your assessment is, the less the chance is that you will need advanced skills. **************Plan your next getaway with AOL Travel. Check out Today's Hot 5 Travel Deals! (http://travel.aol.com/discount-travel?ncid=emlcntustrav00000001) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 Yup. If there's one thing I've tried to impress upon my medic students over the years, it's that, if they screw up and harm a patient...it probably won't be because of their fancy new paramedic learning. It'll be because they forgot something they've known since EMT-B school. krin135@... wrote: > > or, as Grayson, Kim on, and I have been teaching for years, > " Paramedics may save lives, but Basics save Paramedics.... " > > ck > S. Krin, DO FAAFP > > > In a message dated 10/28/2008 20:54:46 Central Daylight Time, > rob.davis@... <mailto:rob.davis%40armynursecorps.com> > writes: > > The better your assessment is, the less the chance is that you will need > advanced skills. > > **************Plan your next getaway with AOL Travel. Check out > Today's Hot > 5 Travel Deals! > (http://travel.aol.com/discount-travel?ncid=emlcntustrav00000001 > <http://travel.aol.com/discount-travel?ncid=emlcntustrav00000001>) > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 On Thursday, October 30, 2008 09:14, " Grayson " said: > Yup. If there's one thing I've tried to impress upon my medic students > over the years, it's that, if they screw up and harm a patient...it > probably won't be because of their fancy new paramedic learning. It'll > be because they forgot something they've known since EMT-B school. In my experience, it's usually because of something they never even learned in either school. Unfortunately, too many instructors in the shake & bake schools don't want to hear that. Rob Quote Link to comment Share on other sites More sharing options...
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