Re: More Fuel on the Intubation Fire (31% failed prehospital ETI in Miami)

[Guest guest]

Followup question --- why in the hell are we screwing around trying to intubate

a critical trauma patient?  Put in an oral or nasal airway or a supraglottic

airway, get them on a backboard (if warranted), and go to the trauma center. 

An ET tube is not what the patient needs, unless its the ET tube the

anesthesiologist is placing in the patient in the OPERATING ROOM.   How long

are people in EMS going to keep believing that we have any critical

interventions that are so important that a trauma patient can afford to wait on

scene while we do our magic ju-ju.  The reason we take patients to the trauma

center is because they require a surgeon's assessment and/or surgical skills. 

That which delays the surgeon (IE messing around with an ET tube on scene) is

bad.

-Wes Ogilvie, MPA, JD, Lic.P./NREMT-P

-Austin, Texas

More Fuel on the Intubation Fire (31% failed prehospital ETI in Miami)

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@...

BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

approximately 3800 emergency admissions per year. In this study, we sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors associated

with PHI. METHODS: A prospective observational study was conducted

evaluating trauma patients who had emergency prehospital airway management

and were admitted during the period between August 2003 and June 2006. The

PHI was considered a failure if the initial assessment determined improper

placement of the endotracheal tube or if alternative airway management

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the trauma

center. Of those, 203 had been initially intubated in the field by emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18 of

63 (29%) surviving to discharge. These patients had rescue airway management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality between

those patients who were properly intubated and those who were not. Several

other variable

s, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations. CONCLUSION:

This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center. We found no difference in mortality between

patients who were properly intubated and those who were not, supporting the

use of bag-valve-mask as an adequate method of airway management for

critically ill trauma patients in whom intubation cannot be achieved

promptly in the prehospital setting.

[Guest guest]

Wes,

take a deep breath (LOL) and re-read what you wrote. I will do the

same. Are we sure that we want to transport a patient in a big fast

hurry that does not have a patent airway or as could be the case, I am

misinterpreting your post. My medics have the skills necessary to get

that ET and I would like them to be able to continue this process. Not

forget it because most of those attempting it in these surveys can't

intubate a #3 washtub.

Andy Foote

More Fuel on the Intubation Fire (31% failed prehospital ETI

in Miami)

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center

perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@...

BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

approximately 3800 emergency admissions per year. In this study, we

sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors

associated

with PHI. METHODS: A prospective observational study was conducted

evaluating trauma patients who had emergency prehospital airway

management

and were admitted during the period between August 2003 and June 2006.

The

PHI was considered a failure if the initial assessment determined

improper

placement of the endotracheal tube or if alternative airway management0D

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the

trauma

center. Of those, 203 had been initially intubated in the field by

emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18

of

63 (29%) surviving to discharge. These patients had rescue airway

management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6),

or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality

between

those patients who were properly intubated and those who were not.

Several

other variable

s, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations.

CONCLUSION:

This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center. We found no difference in mortality between

patients who were properly intubated and those who were not, supporting

the

use of bag-valve-mask as an adequate method of airway management for

critically ill=2

0trauma patients in whom intubation cannot be achieved

promptly in the prehospital setting.

[Guest guest]

And the 31% were not all were improperly placed tubes they were patients that

had alternative airways such as combi.

This is the part of the 31% that should be cause for concern:

" An additional 25 of 63 patients (12%) had unrecognized esophageal intubations

discovered upon the initial airway assessment performed on arrival. "

Are Paramedics failing to confirm placement, failing to reconfirm after moving,

failing to use capnography?

Renny

\

>

> Wes,

>

> take a deep breath (LOL) and re-read what you wrote. I will do the

> same. Are we sure that we want to transport a patient in a big fast

> hurry that does not have a patent airway or as could be the case, I am

> misinterpreting your post. My medics have the skills necessary to get

> that ET and I would like them to be able to continue this process. Not

> forget it because most of those attempting it in these surveys can't

> intubate a #3 washtub.

>

>

> Andy Foote

>

>

> More Fuel on the Intubation Fire (31% failed prehospital ETI

> in Miami)

>

>

>

>

>

>

> Anesth Analg. 2009 Aug;109(2):489-93.

>

> Prehospital intubations and mortality: a level 1 trauma center

> perspective.

> Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

>

> Department of Anesthesiology, School of Medicine, University of

> Miami, Miami, Florida 33136, USA. mcobas@...

>

> BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

> approximately 3800 emergency admissions per year. In this study, we

> sought

> to determine the incidence of failed prehospital intubations (PHI), its

> correlation with hospital mortality, and possible risk factors

> associated

> with PHI. METHODS: A prospective observational study was conducted

> evaluating trauma patients who had emergency prehospital airway

> management

> and were admitted during the period between August 2003 and June 2006.

> The

> PHI was considered a failure if the initial assessment determined

> improper

> placement of the endotracheal tube or if alternative airway management0D

> devices were used as a rescue measure after intubation was attempted.

> RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

> interventions performed by an anesthesiologist upon arrival at the

> trauma

> center. Of those, 203 had been initially intubated in the field by

> emergency

> medical services personnel, with 74 of 203 (36%) surviving to discharge.

> When evaluating the success of the intubation, 63 of 203 (31%) met the

> criteria for failed PHI, all of them requiring intubation, with only 18

> of

> 63 (29%) surviving to discharge. These patients had rescue airway

> management

> provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6),

> or a

> cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

> unrecognized esophageal intubations discovered upon the initial airway

> assessment performed on arrival. We found no difference in mortality

> between

> those patients who were properly intubated and those who were not.

> Several

> other variable

> s, including age, gender, weight, mechanism of injury,

> presence of facial injuries, and emergency medical services were not

> correlated with an increased incidence of failed intubations.

> CONCLUSION:

> This prospective study showed a 31% incidence of failed PHI in a large

> metropolitan trauma center. We found no difference in mortality between

> patients who were properly intubated and those who were not, supporting

> the

> use of bag-valve-mask as an adequate method of airway management for

> critically ill=2

> 0trauma patients in whom intubation cannot be achieved

> promptly in the prehospital setting.

>

>

[Guest guest]

I think this is the most telling sentence from the abstract: " We found no

difference in mortality between those patients who were properly intubated and

those who were not. "

If we aren't impacting mortality levels of those who need it most, then just

what are we doing? This begs the question of should we be worrying about

advanced airway procedures at all if it's not going to change outcomes,

irregardless of how well we do them or how much scene time it takes to do them.

If we are going to do a procedure, any procedure, then it needs to be done well

and it needs to be shown to have a positive impact on patient outcomes. And if

mortality isn't the correct measurement for this particular patient outcomes

(though it is used almost universally for every health issue), then what would

be the correct measurement of the impact of advanced airways in the field?

Barry

Barry Sharp, MSHP, CHES

Tobacco Prevention & Control Program Coordinator

Mental Health and Substance Abuse Division

________________________________

From: texasems-l [mailto:texasems-l ] On Behalf

Of spenair

Sent: Friday, July 31, 2009 11:33 AM

To: texasems-l

Subject: Re: More Fuel on the Intubation Fire (31% failed

prehospital ETI in Miami)

And the 31% were not all were improperly placed tubes they were patients that

had alternative airways such as combi.

This is the part of the 31% that should be cause for concern:

" An additional 25 of 63 patients (12%) had unrecognized esophageal intubations

discovered upon the initial airway assessment performed on arrival. "

Are Paramedics failing to confirm placement, failing to reconfirm after moving,

failing to use capnography?

Renny

\

>

> Wes,

>

> take a deep breath (LOL) and re-read what you wrote. I will do the

> same. Are we sure that we want to transport a patient in a big fast

> hurry that does not have a patent airway or as could be the case, I am

> misinterpreting your post. My medics have the skills necessary to get

> that ET and I would like them to be able to continue this process. Not

> forget it because most of those attempting it in these surveys can't

> intubate a #3 washtub.

>

>

> Andy Foote

>

>

> More Fuel on the Intubation Fire (31% failed prehospital ETI

> in Miami)

>

>

>

>

>

>

> Anesth Analg. 2009 Aug;109(2):489-93.

>

> Prehospital intubations and mortality: a level 1 trauma center

> perspective.

> Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

>

> Department of Anesthesiology, School of Medicine, University of

> Miami, Miami, Florida 33136, USA. mcobas@...

>

> BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

> approximately 3800 emergency admissions per year. In this study, we

> sought

> to determine the incidence of failed prehospital intubations (PHI), its

> correlation with hospital mortality, and possible risk factors

> associated

> with PHI. METHODS: A prospective observational study was conducted

> evaluating trauma patients who had emergency prehospital airway

> management

> and were admitted during the period between August 2003 and June 2006.

> The

> PHI was considered a failure if the initial assessment determined

> improper

> placement of the endotracheal tube or if alternative airway management0D

> devices were used as a rescue measure after intubation was attempted.

> RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

> interventions performed by an anesthesiologist upon arrival at the

> trauma

> center. Of those, 203 had been initially intubated in the field by

> emergency

> medical services personnel, with 74 of 203 (36%) surviving to discharge.

> When evaluating the success of the intubation, 63 of 203 (31%) met the

> criteria for failed PHI, all of them requiring intubation, with only 18

> of

> 63 (29%) surviving to discharge. These patients had rescue airway

> management

> provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6),

> or a

> cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

> unrecognized esophageal intubations discovered upon the initial airway

> assessment performed on arrival. We found no difference in mortality

> between

> those patients who were properly intubated and those who were not.

> Several

> other variable

> s, including age, gender, weight, mechanism of injury,

> presence of facial injuries, and emergency medical services were not

> correlated with an increased incidence of failed intubations.

> CONCLUSION:

> This prospective study showed a 31% incidence of failed PHI in a large

> metropolitan trauma center. We found no difference in mortality between

> patients who were properly intubated and those who were not, supporting

> the

> use of bag-valve-mask as an adequate method of airway management for

> critically ill=2

> 0trauma patients in whom intubation cannot be achieved

> promptly in the prehospital setting.

>

>

[Guest guest]

By all means, if you can get the ET tube, get it.  What I'm just saying is not

to get tunnel vision.  The patient needs ventilation (by the most effective

means possible) en route to a surgeon.  In other words, Andy, we agree.

-Wes

More Fuel on the Intubation Fire (31% failed prehospital ETI

in Miami)

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center

perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@...

BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

approximately 3800 emergency admissions per year. In this study, we

sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors

associated

with PHI. METHODS: A prospective observational study was conducted

evaluating trauma patients

who had emergency prehospital airway

management

and were admitted during the period between August 2003 and June 2006.

The

PHI was considered a failure if the initial assessment determined

improper

placement of the endotracheal tube or if alternative airway management0D

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the

trauma

center. Of those, 203 had been initially intubated in the field by

emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18

of

63 (29%) surviving to discharge. These patients had rescue airway

management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6),

or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality

between

those patients who were properly intubated and those who were not.

Several

other variable

s, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations.

CONCLUSION:

This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center. We

found no difference in mortality between

patients who were properly intubated and those who were not, supporting

the

use of bag-valve-mask as an adequate method of airway management for

critically ill=2

0trauma patients in whom intubation cannot be achieved

promptly in the prehospital setting.

[Guest guest]

By all means, if you can get the ET tube, get it.  What I'm just saying is not

to get tunnel vision.  The patient needs ventilation (by the most effective

means possible) en route to a surgeon.  In other words, Andy, we agree.

-Wes

More Fuel on the Intubation Fire (31% failed prehospital ETI

in Miami)

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center

perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@...

BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

approximately 3800 emergency admissions per year. In this study, we

sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors

associated

with PHI. METHODS: A prospective observational study was conducted

evaluating trauma patients

who had emergency prehospital airway

management

and were admitted during the period between August 2003 and June 2006.

The

PHI was considered a failure if the initial assessment determined

improper

placement of the endotracheal tube or if alternative airway management0D

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the

trauma

center. Of those, 203 had been initially intubated in the field by

emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18

of

63 (29%) surviving to discharge. These patients had rescue airway

management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6),

or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality

between

those patients who were properly intubated and those who were not.

Several

other variable

s, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations.

CONCLUSION:

This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center. We

found no difference in mortality between

patients who were properly intubated and those who were not, supporting

the

use of bag-valve-mask as an adequate method of airway management for

critically ill=2

0trauma patients in whom intubation cannot be achieved

promptly in the prehospital setting.

[Guest guest]

By all means, if you can get the ET tube, get it.  What I'm just saying is not

to get tunnel vision.  The patient needs ventilation (by the most effective

means possible) en route to a surgeon.  In other words, Andy, we agree.

-Wes

More Fuel on the Intubation Fire (31% failed prehospital ETI

in Miami)

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center

perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@...

BACKGROUND: Ryder Trauma Center is a Level 120trauma center with

approximately 3800 emergency admissions per year. In this study, we

sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors

associated

with PHI. METHODS: A prospective observational study was conducted

evaluating trauma patients

who had emergency prehospital airway

management

and were admitted during the period between August 2003 and June 2006.

The

PHI was considered a failure if the initial assessment determined

improper

placement of the endotracheal tube or if alternative airway management0D

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the

trauma

center. Of those, 203 had been initially intubated in the field by

emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18

of

63 (29%) surviving to discharge. These patients had rescue airway

management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6),

or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality

between

those patients who were properly intubated and those who were not.

Several

other variable

s, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations.

CONCLUSION:

This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center. We

found no difference in mortality between

patients who were properly intubated and those who were not, supporting

the

use of bag-valve-mask as an adequate method of airway management for

critically ill=2

0trauma patients in whom intubation cannot be achieved

promptly in the prehospital setting.