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Henry E. Wang, MD, MS 1/6/2019
Do not reproduce without permission. 1
Controversies in Prehospital Endotracheal Intubation
Henry E. Wang, MD, MS
Professor and Vice Chair for Research
Department of Emergency Medicine
The University of Texas Health Science Center at Houston
McGovern Medical School at UTHealth
McGovern Medical School at UTHealth
Disclosures
• NIH Grant Support • UH2/UH3-HL125163
• PI, Pragmatic Airway Resuscitation Trial
Henry E. Wang, MD, MS 1/6/2019
Do not reproduce without permission. 2
McGovern Medical School at UTHealth
Why Intubate in the Field?
• Provide direct conduit to lungs
• Improve ventilation
• Prevent aspiration
• Parallels in-hospital care
• Ultimate goal � “Save lives”
www.trauma.org
McGovern Medical School at UTHealth
“Does Prehospital Intubation Improve Outcomes
(Save Lives)?”
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Does Intubation Save Lives?
• >20 studies of prehospital intubation and outcome (survival)
• Recurrent theme: • Prehospital intubation associated with increased risk of death
• Prehospital intubation associated with poorer neurological outcome
McGovern Medical School at UTHealth
Prehospital Intubation of Children
• Gausche, JAMA 2000
• RCT
• [BVM ± ETI] vs. BVM-only
• 830 children
• No difference in survival
• No difference in neurological outcome
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Prehospital RSI for TBI
• Davis, J Trauma 2003
• Implementation of Prehospital
Rapid Sequence Intubation
• 209 pts compared with 627
historical controls
• RSI associated with increased
death
• OR: 1.6 [1.1-2.2]
McGovern Medical School at UTHealth
Prehospital Intubation and TBI
• Wang, et al., Ann Emerg Med 2004
• Pennsylvania statewide trauma data
• 4,098 TBI • Prehospital vs. Emergency Department ETI
• Excluded non-intubated cases
• Prehospital Intubation • 4x increased death
• 1.6x increased poor neuro outcome
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
“Are Poor Outcomes Due to Errors?”
McGovern Medical School at UTHealth
Endotracheal Tube Misplacement
• Katz and Falk, Ann Emerg Med 1999
• N=108 prehospital intubations
• Systematic reconfirmation in ED
• 25% tube misplacement rate
• 2/3 esophageal
• 1/3 above vocal cords
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Oxygen Desaturation and Bradycardia
• Dunford, Annals EM 2004
• San Diego RSI Trial
• N=152 RSI patients
• Continuously recorded waveforms:
• Heart Rate
• Oxygen Saturation
• End-Tidal Capnography
McGovern Medical School at UTHealth
Dunford, et al. Ann Emerg Med 2004
ETCO2ETCO2
HRHR
SaO2SaO2
Oxygen Desaturation and Bradycardia
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Oxygen Desaturation and Bradycardia
• Oxygen desaturation: 31 (57%)
• Median duration: 160 seconds (IQR 48 to 272)
• Median desaturation (SpO2): 22%
• Bradycardia: 6 (19%)
• Pulse rate
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Intubation � Hyperventilation � BAD
• Harmful in TBI
• ↑ Vent � ↓ pCO2
� ↓ Cerebral Perfusion
• Davis, J Trauma 2004
• May be harmful during CPR
• ↑ Vent � ↑ Intrathoracic Pressure
� ↓ Coronary Perfusion
• Aufderheide Crit Care Med 2004
• Aufderheide Circulation 2004
McGovern Medical School at UTHealth
CPR Chest Compressions
• ACLS Guidelines:
• “Avoid CPR Chest
Compression Interruptions”
• New CPR detection
technology
• Can “see” delivered chest
compressions
Henry E. Wang, MD, MS 1/6/2019
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Example of CPR Interruption from Intubation
ET Tube
Placement
30 sec CPR
Interruption
ETCO2 Signal
McGovern Medical School at UTHealth
Intubation-Associated Chest Compression Interruptions
• Wang, Annals EM 2009
• Pittsburgh
• N=100
• Review of CPR process files and audio recordings
• Identified all CPR interruptions due to intubation efforts
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
0 1 0
2 0
3 0
4 0
P e rc
e n ta
g e o
f P
a ti e n ts
1 2 3 4 5 6 7 8 9 Total Number of CPR Interruptions
Intubation-Associated CPR Interruptions
Median: 2 Interruptions
(IQR: 1-3)
Min 1, Max 9
30% >2 Interruptions
Wang, et al., Ann Emerg Med 2009
Pittsburgh, n=100
0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 Duration (sec)
Sum
Subsequent
First
Duration of Intubation-Associated CPR Interruptions
First CPR Interruption
Median: 46.5 sec (IQR: 23.5-73)
Min 7, Max 221
~30% >60 sec
Subsequent CPR Interruptions
Median: 35 sec (IQR: 21-58)
Min 7, Max 199
~20% >60 sec
Sum of All CPR Interruptions
Median: 109.5 sec (IQR: 54-198)
Min 13, Max 446
~25% >180 sec
Wang, et al., Ann Emerg Med 2009
Henry E. Wang, MD, MS 1/6/2019
Do not reproduce without permission. 11
“Does Training Play a Role?”
Intubation is Difficult in Prehospital Mosh Pit
“There’s no such
thing as an easy
prehospital airway”
“Paramedics need
exceptional
intubation skills”
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
How Many Intubations Do You Need to Graduate in the US?
• Emergency Med Residents 35
• Anesthesia Residents 20-57
• CRNA Students 200
• Paramedic Students 5
0 1 0
2 0
3 0
4 0
P e rc
en ta
g e o
f P
ro g ra
m s
1-4 hrs 5-8 hrs 9-16 hrs 17-32 hrs >32 hrs OR Hours
Paramedic Student Operating Room Training Hours
Median 17-32 hours
Johnston, et al., Acad Emerg Med 2006
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Paramedic Student Operating Room Barriers
• Competition from other
students
• Widespread Laryngeal
Mask Airway use
• Anesthesiologists’
medicolegal concerns
McGovern Medical School at UTHealth
“Skill”
(“Proficiency”) =
Baseline
Training +
Regular
Application
Intubation Skill
Henry E. Wang, MD, MS 1/6/2019
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Intubations Per Paramedic Pennsylvania 2003
Median ETI: 1 (IQR 0-3)
39% performed no ETI
67% performed 2 or fewer ETI
Wang, et al. Crit Care Med 2005
McGovern Medical School at UTHealth
“We Have a Problem . . .”
• Prehospital ETI clinical benefit not proven
• Prone to error
• Difficult
• Interacts with other interventions
• Performed under worst possible conditions
• Limited training
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
“There is an Alternative…”
Supraglottic Airways (SGA)
• Easier technique
• Less training required
• Similar ventilation to ETI
• Increasing use as primary airway in OHCA
King Laryngeal Tube (LT) Laryngeal Mask Airway
(LMA)
i-gel
Henry E. Wang, MD, MS 1/6/2019
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McGovern Medical School at UTHealth
Supraglottic Airways Instead of Intubation � COMMON SENSE
• Simple, easy, reliable
• “Put it in… Forget about it…”
• “Move on to the more important parts of resuscitation”
McGovern Medical School at UTHealth
“SGA vs ETI – Unexpected Results”
Henry E. Wang, MD, MS 1/6/2019
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ETI vs. SGA in Cardiac Arrest ROC PRIMED Trial