Pearls for ED Airway Management 12/26/2013

Size: px

Start display at page:

Download "Pearls for ED Airway Management 12/26/2013"

Bertram Montgomery
5 years ago
Views:

Red Flags in Prehospital Airway Management Henry E.

of Alabama at Birmingham The Current Standard Paramedics have performed prehospital endotracheal

care Science has raised numerous red flags Does Prehospital ETI Save Lives?

1 Red Flags in Prehospital Airway Management Henry E. Wang, MD, MS Associate Professor and Vice Chair for Research Department of Emergency Medicine University of Alabama at Birmingham The Current Standard Paramedics have performed prehospital endotracheal intubation (ETI) for a long time Standard of care for over 25 years Procedure that defines paramedic level care Science has raised numerous red flags Does Prehospital ETI Save Lives? >16 studies of prehospital ETI and outcome (survival) Recurrent theme: Prehospital ETI associated with increased risk of death Prehospital ETI associated with poorer neurological outcome H. Wang, MD 1

2 Prehospital ETI and Outcome Children and RSI Gausche, et al., JAMA 1999 Los Angeles RCT Pediatric ETI vs BVM, n=830 No difference in survival or neurological outcome Davis, et al., J Trauma 2003 San Diego RSI Trial Large-scale ground prehospital RSI for TBI 209 RSI vs. 627 historical non-intubated controls Prehospital RSI increased odds of death Prehospital RSI no effect on neuro outcome Prehospital ETI and Outcome Traumatic Brain Injury Wang, et al., Ann Emerg Med 2004 Pennsylvania Retrospective, statewide trauma registry 4,098 TBI patients Compared Prehospital ETI vs ED-ETI Excluded non-intubated cases Prehospital ETI 4x increased odds of death Prehospital ETI 1.6x increased odds of poor neuro outcome Prehospital ETI and Outcome Cardiac Arrest Studnek, et al., Acad Emerg Med 2010 Mecklenberg County, NC 1,142 out-of-hospital cardiac arrests Patients with no ETI attempts Higher ROSC (OR 2.33; ) Higher Survival to Discharge (OR 5.46; ) Hanif, et al., Acad Emerg Med 2010 Los Angeles 1,294 out-of-hospital cardiac arrests BVM (vs. ETI) Higher survival to discharge (OR 4.5; ) H. Wang, MD 2

3 Prehospital ETI and Outcome Cardiac Arrest Egly, et al., PEC 2011 Royal Oak, Michigan 1,515 OHCA Excluded early ROSC ETI vs. no-eti No difference in survival to discharge (OR 0.52; ) Are Poor Outcomes Due to Adverse Events and Errors? H. Wang, MD 3

: Acad Emerg Med 2003;10(9):961-5 Dunford, et al.

4 Katz and Falk Ann Emerg Med 2001 Prospective, observational study of 108 field intubations arriving at an urban ED 25% Misplaced 2/3 esophageal 1/3 above vocal cords Themes echoed by similar studies Jones JH, et al.: Acad Emerg Med 2004;11(6):707-9 Jemmett ME, et al.: Acad Emerg Med 2003;10(9):961-5 Dunford, et al. Ann Emerg Med 2004 San Diego RSI Trial Subset of 152 RSI patients Out of 462 from total trial Continuously recorded waveforms: Heart Rate Oxygen Saturation End-Tidal Capnography Dunford, et al. Ann Emerg Med 2004 H. Wang, MD 4

5 Dunford, et al. Ann Emerg Med (57%) of 54 patients experienced desaturation Median duration: 160 seconds (IQR 48 to 272) Median desaturation (SpO2): 22% 6 (19%) patients experienced bradycardia Pulse rate <50 beats/min Paramedics described intubation as "easy" in 26 (84%) of 31 patients Intubation Hyperventilation BAD Known to be bad in TBI Vent pco2 Cerebral Perfusion Davis DP, et al: J Trauma 2004 Jul;57(1):1-8 May be bad during CPR Vent Intrathoracic Pressure Coronary Perfusion Aufderheide: Crit Care Med 2004;32(9 Suppl):S Aufderheide: Circulation 2004; Prehospital ETI Interrupts CPR American Heart Association 2005 ECC guidelines Continuous CPR Chest Compressions Simulated Paramedic ETI >1 minute CPR interruption Best-case simulated OHCA Abo, et al., Resuscitation 2007 Multiple ETI attempts during OHCA Wang, et al., Acad Emerg Med 2006 H. Wang, MD 5

Example of ETI CPR Interruption 30 sec CPR Interruption ETCO 2 Signal ET Tube Placement Number of ETI-Associated CPR Interruptions Percentage of Patients 0 10 20 30 40 Median: 2 Interruptions (IQR:

6 Example of ETI CPR Interruption 30 sec CPR Interruption ETCO 2 Signal ET Tube Placement Number of ETI-Associated CPR Interruptions Percentage of Patients Median: 2 Interruptions (IQR: 1-3) Min 1, Max 9 30% >2 Interruptions Total Number of CPR Interruptions Duration of ETI-Associated CPR Interruptions First Subsequent First CPR Interruption Median: 46.5 sec (IQR: ) Min 7, Max 221 ~30% >60 sec Subsequent CPR Interruptions Median: 35 sec (IQR: 21-58) Min 7, Max 199 ~20% >60 sec Sum Sum of All CPR Interruptions Median: sec (IQR: ) Min 13, Max ~25% > sec Duration (sec) H. Wang, MD 6

7 Does Skill Play a Role? ( Are We as Good as We Think? ) How Many Tubes Do You Need to Graduate? EM Residents 35 Anesthesia Residents CRNA Students 200 Paramedic Students 5 Paramedic Student ETI Learning Curve Wang, et al., Prehosp Emerg Care 2005 Magic Number: ETI H. Wang, MD 7

OR Training Hours per Student Median 17-32 hours Percentage of Programs 0 10 20 30 40 1-4 hrs 5-8 hrs 9-16 hrs 17-32 hrs >32 hrs OR Hours Johnston, et al.

8 OR Training Hours per Student Median hours Percentage of Programs hrs 5-8 hrs 9-16 hrs hrs >32 hrs OR Hours Johnston, et al., AEM 2006 Program Director Frustration We are seeing ORs completely shut out paramedic students. Our local hospital [anesthesia] group refuses to have students in the OR Students must drive two hours each way for OR experiences. We had a hospital for intubations until they said we would be required to pay. Securing OR time for ETI is the single most difficult aspect of my job as program director. Mannequins and Simulators? Few studies Plastic Flesh Levitan: Plastic does not recreate the mush of live structures Sim-man cannot recreate Jabba s airway Sim-man cannot recreate heterogeneity of airways H. Wang, MD 8

(IQR 0-3) 39% performed no ETI 67% performed 2 or fewer ETI

9 Skill ( Proficiency ) = Baseline Training + Regular Application Number of ETI 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 ETI Across Pennsylvania H. Wang, MD 9

10 Does ETI Experience Matter? Pennsylvania Statewide EMS Data Year Cumulative Experience 4,846 Rescuers 65,586 ETI Linked to Outcomes (Dead/Alive) Only 33,117 Patients Probabilistic Linkage EMS Data (PAEMS) Hospital Discharge (PHC4) Death (PA Death) NO LINKAGE Alive Dead Outcomes Does ETI Experience Matter? ETI Experience = Survival Rescuer Cumulative ETI Experience Cardiac Arrests > ( ) 1.13 ( ) 1.02 ( ) Referent Rescuer Cumulative ETI Experience Medical Non-Arrests > ( ) 1.29 ( ) 1.16 ( ) Referent Rescuer Cumulative ETI Experience Trauma Non-Arrests > ( ) 1.25 ( ) 0.92 ( ) Referent Adjusted Odds Ratio (Survival) ETI Success Rates - How Good are We? Meta-Analysis (Hubble, PEC 2010) Pooled 86.3% ( %) Cardiac arrest 91.2% ( %) RSI 96.1% ( %) H. Wang, MD 10

11 Not Included Partially Included Included Pearls for ED Airway Management 12/26/2013 Out-of-Hospital Airway Management in the United States National Emergency Medical Services Information System (NEMSIS) National standard data definitions National aggregate EMS data set 2008 public-use research data set 16 states 4.3 million EMS events States Included in NEMSIS 2008 Public-Use Data Set Endotracheal Intubation Success (n=10,356) Univariable Successful ETI / (% Successful ETI; Odds Ratio ETI Subgroup Subgroup Total 95% CI) (95% CI) Endotracheal Intubation 6,482 / 8,418 (77.0; ) - Cardiac Arrests 3,494 / 4,482 (78.0; ) Referent Non-Arrest Medical 616 / 846 (72.8; ) 0.8 ( ) Non-Arrest Injury 417 / 505 (82.6; ) 1.3 ( ) Pediatric age<10 years 295 / 397 (74.3; ) Referent Pediatric age years 228 / 289 (78.9; ) 1.3 ( ) Adult age>19 years 5,829 / 7,552 (77.2; ) 1.2 ( ) Rapid-sequence intubation 289 / 355 (81.4; ) N/A Endotracheal Intubation Success (n=10,356) Univariable Successful ETI / (% Successful ETI; Odds Ratio ETI Subgroup Subgroup Total 95% CI) (95% CI) Endotracheal Intubation 6,482 / 8,418 (77.0; ) - Cardiac Arrests 3,494 / 4,482 (78.0; ) Referent Non-Arrest Medical 616 / 846 (72.8; ) 0.8 ( ) Non-Arrest Injury 417 / 505 (82.6; ) 1.3 ( ) Pediatric age<10 years 295 / 397 (74.3; ) Referent Pediatric age years 228 / 289 (78.9; ) 1.3 ( ) Adult age>19 years 5,829 / 7,552 (77.2; ) 1.2 ( ) Rapid-sequence intubation 289 / 355 (81.4; ) N/A H. Wang, MD 11

ETI Success by Census Region WEST 79.7% (77.7-81.6%) NE: 56,844 ND: 39,705 MIDWEST 83.5% (81.9-85.2%) NORTHEAST 85.0% ME: 92,986 (82.6-87.

12 ETI Success by Census Region WEST 79.7% ( %) NE: 56,844 ND: 39,705 MIDWEST 83.5% ( %) NORTHEAST 85.0% ME: 92,986 ( %) MN: 627,393 NH: 60,278 IA: 141,216 NJ: 899 NC: 2,085,369 NV: 86,535 CO: 222,290 AL: 270,775 Not Included Partially Included NM: 16,797 OK: 3,844 MO: 131,654 FL: 523,455 Included Hawaii: 23,728 SOUTH 70.9% ( %) Houston, We Have a Problem... Should paramedics Prehospital ETI is (very) complex and intubate at difficult all? No proven clinical benefit Prone to error (some unrecognized) Interacts with other interventions Performed under worst possible conditions Limited training An Unspeakable Idea H. Wang, MD 12

Supraglottic Airway Devices First Generation EOA PTL Second Generation Combitube LMA

?? Weighing the Options ETI Difficult to Use Difficult to Learn Difficult to Maintain

Skill Fewer Potential Errors Ventilate as Well as ET Tube (we think) Not perfect

ETI: Faster Airway, More Chest Compressions 250 30 sec Airway 200 Savings 150 141 159.

13 Supraglottic Airway Devices First Generation EOA PTL Second Generation Combitube LMA Third Generation King LT Fourth Generation??? Weighing the Options ETI Difficult to Use Difficult to Learn Difficult to Maintain Skill Error-Prone Supraglottic Airways Easy to Use Easy to Learn Easy to Maintain Skill Fewer Potential Errors Ventilate as Well as ET Tube (we think) Not perfect solutions, but have many appealing qualities Combitube vs. ETI: Faster Airway, More Chest Compressions sec Airway 200 Savings sec CPR Savings Seconds Airw ay IV Drug 4th Shock All 4 No CPR Intervention Combitube ETI H. Wang, MD 13

14 It s Already Happening in the USA Kalamazoo, MI Chesterfield County, VA Collier County, FL Dallas, TX Paramedics substituting ETI with Combitube/King for cardiac arrests Decreased CPR hand-off time Increased ROSC/survival best figures in 15 years What About the FDA Mandate to King? FDA order to stop marketing King LT for difficult and emergent airway cases Does not say, stop using device in field Does not say, pull device from market Inconsistent interpretation of order by state EMS officials Some Thoughts on Drug-Facilitated Intubation H. Wang, MD 14

15 Do You Need OR Time for RSI? There are no data to support this, so I m not requiring it for my RSI medics Strongest RSI programs have incorporated OR time Wayne, PEC 2001 OR for baseline training Requirement: 12 ETI/year or else to OR >2000 RSI over 20 years very few complications We know this works Can RSI Potentially Help? Maybe Bernard, Ann Surg 2010 Australian RCT in adult TBI Prehospital RSI vs. Supportive Airway RSI improved 6-mos functional outcome Good (egos 5-8) vs. Poor (egos 1-4) Relative Risk 1.28; No differences in primary endpoint (median egos) or other endpoints (!) 16 hours RSI training, including OR time 97% RSI success rate Rapid-Sequence Airway (RSA)? Braude, et al. PEC 2007 Etomidate + Roc + LMA (Etomidate + Sux + King) Sensible strategy Paranoia of RSI is the I - not the RS King airway easy, reliable, robust If we embraced safer airway techniques, we could (safely) entertain novel airway strategies H. Wang, MD 15

16 Sedation-Facilitated Intubation? Strong consensus Sedation-facilitated intubation requires same system and patient safeguards as for RSI Formulary availability qualification to perform technique Etomidate-only? Jacoby, et al., Ann Emerg Med 2006 Irony no difference in success rates vs. Versed Where do we go from here? Take-Home Messages Do not stop intubating Have a healthy respect for airway management Far more complex than we imagine Maximize airway training opportunities Airway QA is mandatory Need to keep an open mind to new (unpopular) ideas H. Wang, MD 16

17 How Do I Sell This to My Medics? The clinical objective is airway management Endotracheal intubation is one option - among several options - for achieving airway management You must choose the right mouse trap at the right time An RCT of ETI? ( Don t hold your breath ) An RCT of Adult ETI vs. [King]? Can It Be Done? Must focus on cardiac arrest Trauma ETI require sux much more complicated Sample sizes for cardiac arrest are astronomical 22,000+ patients No clean pilot data Practice has already shifted But we have no idea who is doing King-first Little support from scientific community R.I.P. E.T.I. R.I.P. R.C.T. E.T.I. R.C.T. H. Wang, MD 17

Wang, MD, MS Department of Emergency Medicine University of Alabama at Birmingham 619

18 It s Not Over til the Fat Lady Sings The Show s Not Over Yet Please attend Friday s scientific session Unexpected results May turn everything upside-down Contact Henry E. Wang, MD, MS Department of Emergency Medicine University of Alabama at Birmingham th St. South, OHB 233 Birmingham, AL (205) hwang@uabmc.edu H. Wang, MD 18

1/9/2015. Red Flags in Prehospital Airway Management. H. Wang, MD 1. Red Flags in Prehospital Airway Management. Disclosures. The Current Standard

1/9/2015. Red Flags in Prehospital Airway Management. H. Wang, MD 1. Red Flags in Prehospital Airway Management. Disclosures. The Current Standard Red Flags in Prehospital Airway Henry E. Wang, MD, MS Professor and Vice Chair for Research Department of Emergency Medicine University of Alabama at Birmingham Disclosures NIH Grant Support UH2-HL125163