Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks?
ABSTRACT Out-of-hospital rescuers often perform tracheal intubation (TI) prior to other cardiopulmonary resuscitation (CPR) interventions. TI is a complex and error-prone procedure that may interfere with other key resuscitation tasks. We compared the effects of TI versus esophageal tracheal combitube (ETC) insertion on the accomplishment of other interventions during simulated cardiopulmonary resuscitation.
In this prospective trial using a human simulator, two-paramedic teams simulated resuscitation of a ventricular fibrillation cardiopulmonary arrest using standard Advanced Cardiac Life Support guidelines. In each of two trials, teams used either TI or ETC as the primary airway device. Following delivery of three rescue shocks, we measured time intervals to successful airway placement, intravenous (IV) line insertion, drug administration, delivery of fourth rescue shock and completion of all four tasks. We also measured the total time without chest compressions. We compared task completion times using non-parametric statistics (Wilcoxon signed-ranks test) with a Bonferroni-adjusted p-value of 0.008.
Twenty teams each completed two scenarios. Participants required a median of 172.5 s (IQR: 146.5-225.5) to accomplish all four tasks. Elapsed time to airway placement was significantly less for ETC than TI (median difference 26.5 s (IQR 13-44.5), p=0.002). Time without chest compressions was less for ETC than TI (median difference 8.5 s (IQR 2.5-23.5), p=0.005). There were no differences between ETC and TI in times to IV placement (median difference 23.5 s (IQR -20 to 61), p=0.11), drug delivery (39.5 s (IQR -18 to 63), p=0.07), delivery of fourth rescue shock (39.5 s (IQR -21.5 to 87.5), p=0.07) or completion of all four tasks (33 s (IQR -11 to 74.5), p=0.08).
Compared with TI, ETC reduced time to airway placement and time without chest compressions, but did not affect elapsed times to accomplish other interventions. Additional time differences may be realized if translated to clinical out-of-hospital conditions.
- SourceAvailable from: Francis GuyettePrehospital Emergency Care 01/2007; 11(1):56-61. DOI:10.1080/10903120601021150 · 1.81 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Prior efforts have linked field endotracheal intubation (ETI) with increased out of hospital (OOH) time, but it is not clear if the additional time delay is due to the procedure, patient acuity, or transport distance. We sought to assess the difference in OOH time among trauma patients with and without OOH-ETI after accounting for distance and other clinical variables. Retrospective cohort analysis of trauma patients 14 years or older transported by ground or air to one of two Level 1 trauma centers from January 2000 to December 2003. Geographical data were probabilistically linked to trauma registry records for transport distance. Trauma registry OOH time (interval from 9-1-1 call to hospital arrival) was validated against a subset of linked ambulance records using Bland-Altman plots and tested by using the Spearman rank correlation coefficient. Based on the validation, the sample was restricted to patients with OOH time 100 minutes or less. The propensity for OOH-ETI was calculated by using field vital signs, demographics, mechanism, transport mode, comorbidities, Abbreviated Injury Scale head injury 3 or greater, injury severity score, blood transfusion, and major surgery. Multivariable linear regression (outcome = total OOH time) was used to assess the time increase (minutes) associated with OOH-ETI after adjusting for distance, propensity for OOH-ETI, and mode of transport. A total of 8,707 patients were included in the analysis, of which 570 (6.5%) were intubated in the field. Adjusted only for distance, OOH times averaged 6.1 minutes longer (95% CI 4.2-7.9) among patients intubated with RSI. After including other covariates, OOH time was 10.7 minutes (95% CI 7.7-13.8) longer among patients with RSI and 5.2 minutes (95% CI 2.2-8.1) longer among patients with conventional ETI. The time difference was greatest farther from the hospital. Patients with OOH-ETI have increased total OOH time, especially among those using RSI, even after accounting for distance and other clinical factors. Injured patients may benefit from airway management techniques that require less time for execution.Prehospital Emergency Care 04/2007; 11(2):224-9. DOI:10.1080/10903120701205208 · 1.81 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: We sought to evaluate the association between three key out-of-hospital endotracheal intubation (ETI) errors and patient outcomes. We prospectively collected multicenter data on out-of-hospital ETI attempted by Emergency Medical Service (EMS) rescuers. We probabilistically linked these data to statewide EMS, death and hospital discharge data sets. The key ETI error events were (1) endotracheal tube misplacement or dislodgement, (2) multiple ETI attempts (> or =4 laryngoscopies) and (3) failed ETI. The primary outcomes were death (survival to hospital discharge) and secondary complications identified through ICD-9 discharge diagnoses. Using Cox regression with heavyside functions, we identified the associations between out-of-hospital ETI errors and early (in the field or emergency department) and later (on or after hospital admission) death. We censored non-linked cases, adjusted for important clinical covariates, and used a shared frailty regression model to account for clustering by EMS agency. We evaluated the associations between out-of-hospital ETI errors and secondary complications using univariable odds ratios with exact 95% confidence intervals. Of 1954 out-of-hospital ETI, 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Of the 1196 (61%) cases linked to outcomes, 872 (73%) died and 323 (27%) survived to hospital discharge. ETI errors were not associated with early death (tube misplacement or dislodgement: Hazard Ratio 0.98, 95% CI 0.65-1.47; multiple ETI attempts: 1.22, 0.80-1.85; failed ETI: 1.10, 0.88-1.39) or later death (tube misplacement or dislodgement: 0.40, 0.10-1.62; multiple ETI attempts: 1.77, 0.23-13.30; failed ETI: 0.76, 0.47-1.25). Pneumonitis was associated with failed ETI (n=20, 19%; univariable OR 2.54; 95% CI 1.24-5.25). Out-of-hospital ETI errors are not associated with mortality. Failed out-of-hospital ETI increases the odds of pneumonitis.Resuscitation 10/2008; 80(1):50-5. DOI:10.1016/j.resuscitation.2008.08.016 · 3.96 Impact Factor