One Good Attempt Doesn t Deserve Another: What Happens When You Limit ET Tube Placement to One Try?
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1 One Good Attempt Doesn t Deserve Another: What Happens When You Limit ET Tube Placement to One Try? John K. Griswell, MD, FACEP
2 The challenge... How do we take care of the airway needs of our patients without doing harm?
3 San Diego Trial 13 minute LONGER scene time when RSI used on scene vs. en route Unrecognized 22% decrease in SpO 2 in 57% of reviewed cases, lasting ~160 sec. Intubation described as easy by paramedic in 84% of desaturated cases Hyperventilation?
4 Out-of-hospital endotracheal intubation and outcome after traumatic brain injury Henry E. Wang MD, MPH,, Andrew B. Peitzman MD, Laura D. Cassidy PhD, P. David Adelson MD and Donald M. Yealy MD From the Department of Emergency Medicine (Wang, Yealy), Department of Surgery (Peitzman), and Department of Neurosurgery (Adelson), University of Pittsburgh School of Medicine; and the Department of Biostatistics, University of Pittsburgh (Cassidy), Pittsburgh, PA. Annals of Emergency Medicine Volume 44, Issue 5, November 2004, Pages
5 Out-of-hospital (vs emergency department) ET intubation was associated with increased adjusted odds of: Death (3.99; 95% CI 3.21 to 4.93) Poor neurologic outcome (1.61; 95% CI 1.15 to 2.26) Moderate or severe functional impairment (FIS 6 to 15; OR 1.92; 95% CI 1.40 to 2.64) Severe functional impairment (FIS 11 to 15; OR 1.80; 95% CI 1.29 to 2.52)
6 Average Scene Times Average Scene Times (January March 2006) N=10 N=641 N=42 Intubated on First Attempt Intubated on Second Attempt Intubated on Third Attempt Average
7 Average Scene Times Average Scene Times (January March 2006) N=49 Not Intubated on First Attempt and No Combitube Attempted N=64 N=5 Not Intubated on First Attempt and Combitube Attempted Not Intubated after Multiple Attempts and No Combitube Attempted N=27 Not Intubated after Multiple Attempts and Combitube Attempted Average
8 What to do?
9 MedStar ET Intubation Success Rates Intubation Success Rate Jan-04 Mar-04 May-04 Jul-04 Sep-04 Nov-04 Jan-05 Mar-05 May-05 Jul-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 % of Patients Successfully Inbutated 2 per. Mov. Avg. (% of Patients Successfully Inbutated)
10 15. IF ETT Intubation is unsuccessful after ONE attempt, insert a Combitube.
11 Total Calls July 2005 December Total Number of Calls /05-3/06 4/06-12/06
12 Advanced Airway Attempts July 2005 December /05-3/06 4/06-12/ Total Calls With Advanced Airway Attempted Total ETT Attempts Patients With Combitubes Attempted Combitube Attempted First Total Number of Patients w/o Definite Airway
13 ETT Intubations July 2005 December % 90.00% 80.00% 70.00% 84.18% 77.83% 92.39% 96.30% 60.00% 50.00% 40.00% 7/05-3/06 4/06-12/ % 20.00% 10.00% 0.00% Intubation Success Rate Of Patients Intubated - % Intubated on First Attempt
14 Combitube Success Rates July 2005 December % 90.00% 80.00% 70.00% 91.67% 94.20% 60.00% 50.00% 40.00% 7/05-3/06 4/06-12/ % 20.00% 10.00% 0.00% Combitube Success Rate
15 BVM Usage July 2005 December /05-3/06 4/06-12/06 0 Total Airway Calls Total Airway Calls With BVM Used Only
16 BVM Usage Only July 2005 December % 45.00% 40.00% 35.00% 39.82% 42.67% 30.00% 25.00% 20.00% 7/05-3/06 4/06-12/ % 10.00% 5.00% 0.00% Percent of Airway Calls With BVM Used Only
17 Scene Times July 2005 December /05-3/06 4/06-12/06 BVM Use Only All Advanced Airway Calls Combitube Only w/o ETT Attempt ETT Only w/o Combitube Use ETT + Combitube
18 Results 10% decrease in calls with advanced airway attempted 15% decrease in ETT attempts 113% increase in number of patients with Combitube attempted 146% increase in number of patients with Combitube attempt first
19 Results 22% decrease in patients with advanced airway attempted unsuccessfully 7% decrease in intubation success rate 4% increase in ETT first attempt success 2.7% increase in Combitube success rate
20 Conclusions: Our Experience First attempt % improvement suggests that medics may not prepare as much as they should. Combitube use increased overall and may reflect a future trend.
21 Conclusions: Our Experience Intubation attempts may be limited to one while possibly improving overall ETT intubation success rates. Further study is needed to determine if increased Combitube use is, indeed, safer.
22 Complications associated with the Esophageal- Tracheal Combitube in the pre-hospital setting Vezina,, et al, Can J Anesth; ; Feb, patients 58 patients had 69 complications (13 insertion trauma): aspiration pneumonitis (n=31) pulmonary aspiration (n=16) pneumothorax (n=6) upper airway bleeding (n=4) esophageal laceration (n=3) sc emphysema (n=2) esophageal perforation and mediastinitis (n=2) tongue edema (n=2) tracheal injury (n=1) pneumomediastinum (n=1)
23 Conclusions: Our Experience Further study is also needed to assess whether these airway management trends of more accurate ETT use AND increased Combitube use decreases the adverse outcomes of ETT use reported elsewhere.
24 Thanks to Daniel Ebbett, EMT-P Jon Puryear, NREMT-P
25 Special thanks to Ray Fowler, M.D.
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