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

Henry E. Wang, MD, MS 1/6/2019

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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

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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

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“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

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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

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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