controversies in prehospital endotracheal intubation · pdf file do not reproduce without...

Click here to load reader

Post on 30-May-2020

6 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • 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

    Do not reproduce without permission. 3

    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

    Do not reproduce without permission. 4

    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

    Do not reproduce without permission. 5

    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

    Do not reproduce without permission. 6

    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

    Do not reproduce without permission. 7

    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

    Do not reproduce without permission. 8

    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

    Do not reproduce without permission. 9

    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

    Do not reproduce without permission. 10

    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

    Do not reproduce without permission. 12

    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

    Do not reproduce without permission. 13

    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

    Do not reproduce without permission. 14

    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

    Do not reproduce without permission. 15

    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

    Do not reproduce without permission. 16

    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

    Do not reproduce without permission. 17

    ETI vs. SGA in Cardiac Arrest ROC PRIMED Trial

View more