Un article d Jabre et all décrit de manière relativement précise le quotidien de l'intubation préhospitalière

Out-of-Hospital Tracheal Intubation With Single-Use Versus Reusable Metal Laryngoscope Blades: A Multicenter Randomized Controlled Trial -

Cet article est très intéressant car il permet d'avoir une vision très claire de l'intubation telle qu'elle est réalisée en préhospitalier en France. L'objectif premier était de comparer l'intubation avec lame métallique réutilisable versus non réutilisable et de voir si il y avait une différence en matière d'intubation difficile. Ce n'est pas le cas. Parmi les autres intérêts de ce travail:

l'intubation préhospitalière est réalisée essentiellement lors de la prise en charge d' arrêt cardiaque ou de coma. Le contexte traumatique n'est présent que dans 4% des cas. Ce qui ne correspond pas au contexte d'emploi militaire. Le contrôle des voies aériennes ayant pour objectif essentiel le maintien de la liberté des voies aériennes, puis leur protection contre l'inhalation et enfin la possibilité de réaliser une ventilation contrôlée si les autres paramètres techniques sont accessibles (matériel, oxygène, sédation)

2. La taille de la lame utilisée est une taille 4. Le laryngoscope Truphatek Trulite en dotation est approvisionné en taille 3. Ceci a été jugé suffisant par un panel de praticiens, ce d'autant que les lames de tailles 4 sont aussi plus hautes et pas forcément toujours « insérables » dans la cavité buccale en cas de petite ouverture de bouche.

3. Le recours à des techniques alternatives est prévu, ici le masque laryngé d'intubation qui est utilisé de manière exceptionnelle moins de 1% des cas, contrairement au mandrin d'eschmann/Frova.

4. Parmi les complications immédiates, on constate la fréquence des hypotensions près de 10% et des intubations sélectives ou oesophagiennes également près de 10% des cas. Ces taux observés pour des équipes à priori entraînées illustrent bien que l'enjeu majeur de la médicalisation de l'avant dans le contexte actuel est de disposer de personnel ayant une pratique réelle de l'accès aux voies aériennes supérieures.

Le port de charges lourdes est un élément important à prendre en compte. Vous ne devez pas vous charger de manière inconsidérée. Un équilibre est à trouver entre ce qui est nécessaire pour le combat, l'hydratation, l'alimentation, le matériel santé et VOS CAPACITES PHYSIQUES. Le lien suivant aborde la problématique vue par les américains.

http://www.bordeninstitute.army.mil/other_pub/LoadCarriag...

Le drainage thoracique en condition de combat doit rester l'exception. Il peut se justifier en cas d'échec ou d'insuffisance de l'exsufflation ou de la thoracostomie au doigt. Il peut également s'envisager selon les conditions tactiques si le délai d'EVASAN es long. Le document ci-après présente de manière très didactique la réalisation de ce geste pas si anodin qu'il n'y paraît.

http://www.copacamu.org/IMG/pdf/3-roch.pdf

Contrubution de l'OMLT6 (MC Boulanger A.), une présentation en DARI du 9 Line.

9 line Medevac_dari.pdf

Le 9 Line MEDEVAC request est le message type utilisé pour la réalisation des évacuations sanitaires héliportées en afghanistan. Les exemples donnés dans les divers documents du CITERA présentent ce message. Ils sont actualisés au moment de la révision des ces documents. Ils peuvent donc être légèrement différents de la réalité. Le version actuelle utilisée est présentée dans le lien suivant.

9-Line MEDEVAC Request.pdf

Can J Surg. 2010 June; 53(3): 184–188

Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length

Ball CG et all.

"

Résumé

Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001).

"

Morceau choisi

Although some authors¹³^,¹⁶ have called for 7- to 8-cm needles to ensure that all OPTXs are decompressed, it appears that even catheters as short as 4.5 cm can puncture the heart at standard insertion locations in 2.5% of trauma patients.²⁴ Other complications include chest wall hematoma, hemothorax, empyema and dislodgement in up to 8% of patients.¹⁸^,²⁵ In an attempt to avoid these issues, as well as access the pleural space more reliably, support for axillary NT is increasing.³^,¹⁸^,²²^,²⁵^,³⁹ This lateral location takes advantage of a thinner chest wall (mean 2.6 cm)¹⁶ and is the military’s first choice if under fire because it allows medics to keep a soldier’s body armor in place while achieving decompression.⁴⁰ Although we observed no direct complications in our study, we support the use of a catheter at of least 4.5 cm in length.

Commentaires

Le pneumothorax suffocant est la seconde cause de mort évitable au combat. Sa pris en charge repose sur la décompression de l'air retneu dans la cage thoracique. Outre la thoracostomie au doigt, geste de référence simple et sans danger, il peut être effectué une décompression à l'aiguille. Certains militent pour l'emploi d'un cathéter de grande taille de 8 cm du fait de l'épaisseur de la paroi thoracique, en particulier chez les militaires . Cependant le risque de plaie cardiaque et des gros vaisseaux est relativement important et peut atteindre 2.5% des blessés (1, 2, 3), ce d'autant plus que les ponctions sont habituellement réalisées de manière beaucoup trop médianes.

En condition de combat, une conduite raisonnable est de pratiquer cette exsufflation par voie LATERALE (4) et par ailleurs d'utiliser des cathéters de 5 cm qui apparaissent SUFFISANTS (5)

Cette revue de littérature rappelle quelques données essentielles sur l'emploi des HEA pour le remplissage vasculaire. Il en ressort que le bien fondé de cette pratique n'est pas validé y compris pour les HEA de 3ème génération 130/0,4 dont fait partie le voluven pourtant les moins sujets à complications. Ces dernières sont repréesntées par le risque d'insuffisance rénale, la tendance au saignement et une tendance à l'augmentation de la mortalité. Il n'est pas sans intérêt de faire remarquer que l'HYPERHES est un soluté contennat un HEA de type 2005.

Première lecture

REVIEW ARTICLE
The Efficacy and Safety of Colloid Resuscitation in the Critically Ill
Christiane S. Hartog, MD, Michael Bauer, MD, and Konrad Reinhart, MD

(Anesth Analg 2011;112:156 –64)

Despite evidence from clinical studies and meta-analyses that resuscitation with colloids or crystalloids is equally effective in critically ill patients, and despite reports from high-quality clinical trials and meta-analyses regarding nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of hydroxyethyl starch (HES) solutions, colloids remain popular and the use of HES solutions is increasing worldwide. We investigated the major rationales for colloid use, namely that colloids are more effective plasma expanders than crystalloids, that synthetic colloids are as safe as albumin, that HES solutions have the best risk/benefit profile among the synthetic colloids, and that the third-generation HES 130/0.4 has fewer adverse effects than older starches. Evidence from clinical studies shows that comparable resuscitation is achieved with considerably less crystalloid volumes than frequently suggested, namely, 2-fold the volume of colloids. Albumin is safe in intensive care unit patients except in patients with closed head injury. All synthetic colloids, namely, dextran, gelatin, and HES have dose-related side effects, which are coagulopathy, renal failure, and tissue storage. In patients with severe sepsis, higher doses of HES may be associated with excess mortality. The assumption that third-generation HES 130/0.4 has fewer adverse effects is yet unproven. Clinical trials on HES 130/0.4 have notable shortcomings. Mostly, they were not performed in intensive care unit or emergency department patients, had short observation periods of 24 to 48 hours, used cumulative doses below 1 daily dose limit (50 mL/kg), and used unsuitable control fluids such as other HES solutions or gelatins. In conclusion, the preferred use of colloidal solutions for resuscitation of patients with acute hypovolemia is based on rationales that are not supported by clinical evidence. Synthetic colloids are not superior in critically ill adults and children but must be considered harmful depending on the cumulative dose administered. Safe threshold doses need to be determine in studies in high-risk patients and observation periods of 90 days. Such studies on HES 130/0.4 are still lacking despite its widespread and increasing use. Because there are safer and
equally effective alternatives in the form of crystalloids, use of synthetic colloids should be avoided except in the context of clinical studies.

Seconde lecture

La Société Française d'anesthésie-réanimation rappelle d'ailleurs également ce risque hémorragique y compris pour les HEA 10/0,4 notamment lors d'adminsitration aiguë.

"

L’albumine, les gélatines et l’amidon 130 000/0,4 (Voluven®) n’interfèrent pas, ou quasiment pas avec l’hémostase. La prudence reste toutefois conseillée :
- chez les patients insuffisants rénaux
- en cas de perfusion prolongée ou de volume de colloïdes important ;
- en cas de troubles de l’hémostase acquis ;
- chez les patients traités par antiplaquettaires ou anticoagulants ;
- en présence d’une anémie ou thrombopénie profonde ;
- chez les patients porteurs d’une maladie de Willebrand ;
- chez les patients de groupe sanguin O (ces patients ont spontanément un taux de Willebrand plus bas) ;
- en présence d’un saignement chirurgical actif ;
- en présence d’une transfusion massive ou d’une hypothermie.

Comentaires

Ainsi les effets secondaires des HEA ne sont pas que liés à eur adminsitration répétitive. Dans nos conditions d'emploi , il apparait nécessaire d'observer une certaine retenue dans ll'usage des HEA. Ceci plaide pour l'utilisation des solutés cristalloïdes tel que le Ringer lactate, le sérum salé hypertonique et pose la question d'un recours plus large au gélatines fluides modifiées malgré leur risque allergique (?)

Le choix d'un laryngoscope "tactique" n'est pas simple. C'est un compromis entre la modalité choisie de contrôle des voies aériennes (pas d'intubation, coniotomie ou intubation ?), le poids du laryngoscope, la taille de la lame et les qualités optiques attendues.

Vous dispsoez outre de la boite d'intubation standard du laryngoscope trulite de la société truphatek.

TruLite Mac 234_Open2_2.jpg

Il a été choisi d'approvionner ce laryngoscope en lame fixe de taille 3 qui semble la plus polyvalente. Ce laryngoscope est remarquable de part sa légèreté, la présence d'un manche court et la qualité de la lumière LED fournie. Il est en principe à patient unique.

Pour pallier au problème du choix de la taille de la lame, certains proposent des produits originaux. Ainsi le duoscope de la société PARKER propose deux tailles de lame et un éclairage de grande qualité. sa manipulation est moins aisée car c'est la seconde lame qui sert de manche.

10 % des blessés évacués nécessite une intubation dont 4.7% avant l'embarquement dans le vecteur d'évacuation. Dans ce travail la limite est que nous ne savons pas ce qui relève de blessés au combat , s'il s'agit de blessés militaires, de la répartition des procédures en fonction du contexte. Dans de telles conditions la prise en charge de patients/blessés en arrêt circulatoire est vaine .

J R Army Med Corps. 2010 Sep;156(3):159-61.

Advanced airway management--a medical emergency response team perspective.

Haldane AG.

Selly Oak Hospital, Birmingham. aghaldane1@doctors.org.uk

Abstract

OBJECTIVES: To determine the number of medical emergency response team (MERT) patients undergoing advanced airway management in the peri-evacuation phase and to determine the indications for airway interventions undertaken in flight.

METHODS: This was a retrospective study. Data was collected from patient report and mission debrief forms completed after each MERT mission during Operation HERRICK 10 (April-October 2009). All patients that received advanced airway interventions before or during evacuation were identified.

RESULTS: MERTs were involved in the primary transfer of 534 patients during the period studied, 56 (10.5%) underwent advanced airway management, of which 31 (5.8% of total) were initiated by the MERT in the peri-evacuation phase. Twenty five cases (4.7%) underwent advanced airway management by other pre-hospital providers prior to MERT arrival. Of the 31 advanced airway interventions undertaken in-flight, cardiac arrest was the primary indication in only nine cases.

CONCLUSIONS: The figure of 56 patients requiring advanced airway management is at the higher end of the range expected from the study of historical military data. This may reflect the doctrine of "intelligent tasking", that is sending this physician-led team to the most seriously injured casualties.

Morceaux choisis

1. Intubation et coniotomie sont la base

2. Les indications diffèrent de la médecine préhospitalière civile

"..

The indications for those advanced airway interventions undertaken by the MERT is in keeping with the historical data: Head injury making the biggest group once those inrubated for post-operative resplratory support ie those transferred post-operatively from an FST location rather than direct from the point of wounding are excluded . The majoriry of the cases were trauma (93,5%) with the remaining non-traula causes (6,5%) (table 1); This figure is again similar io the recent US study [11].

.."

Les dernières recommendations portant sur la sédation préhospitalière ont été publiées. L'algorithme suivant est proposé.

1. Remplacez simplement l'ephédrine par de l'adrénaline titrée (1 mg/10 ml, ml par ml pour obtenir un pouls radial perçu).

2. Notez l'emploi de l'AL de glotte

3. Notez le caractère impératif de la sédation après intubation. Cependant il n'y a pas de recommandations fortes concernant le choix midazolam/morphinique ou kétamine/morphinique. Le recours au GammaOH a été proposé en conditions de combat car ne nécessitant qu'une injection IV.

On sait que prévenir l'hypothermie est essentielle pour la survie d'un blessé.

Les principales caractéristiques de la couverture idéale sont résumées sur ce schéma.

Nous disposons de nombreux moyens allant de la couverture simple, de la couverture renforcée, de la couverture triple couche et de la couverture chauffante. Tous les moyens de protection n'ont pas la même efficacité. Cette dernière est pour beaucoup liée à l'épaisseur des protections, leur caractère non compressible et hermétique ainsi que leur réflectivité (Lire). Une fiche mémo est disponible (Voir ici)

Nous connaissons tous également le système heatpac.

charc1_(2).JPG

Mais savez vous que le films d'emballage à bulles (bubble wrap) sont très efficaces ( 1, 2).

Ces produits sont même commercialisés spécifiquement pour les besoins de santé.

Cette vidéo illustre la mise en oeuvre de ce produit Vidéo à voir.

Le consensus européen sur la prise en charge des hémorragies de cause traumatique évoque le recours à l'acide tranexaminique. L'exacyl a largement démontré son efficacité comme moyen pharmacologique d’épargne sanguine péri-opératoire. Son intérêt en traumatologie n'était pas jusqu'à présent bien documenté. L'étude Crash 2 publiée dans le lancet apporte un éclairage nouveau.

Eﬀects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signiﬁ cant haemorrhage (CRASH-2): a randomised, placebo-controlled trial

June 15, 2010 DOI:10.1016/S0140-6736(10)60835-5

10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was signiﬁcantly reduced with tranexamic acid (1463 [14·5%] tranexamic acid group vs 1613 [16·0%] placebo group; relative risk 0·91, 95% CI 0·85–0·97; p=0·0035). The risk of death due to bleeding was signiﬁcantly reduced (489 [4·9%] vs 574 [5·7%]; relative risk 0·85, 95% CI 0·76–0·96; p=0·0077).

Il n'existe pas de protocole d'emploi bien formalisé. Dans l'étude crash 2, une dose de charge de 1 g est administrée en 10 minutes, suivie d'un entretien de 1 g perfusé en 08 h. De faibles posologies seraient efficaces. Certains proposent le régime suivant: bolus IV de 10 mg.kg-1 suivi d’une perfusion continue de 1 mg.kg-1 .h-1. Ce médicament est disponible en dotation.

Pour en savoir plus 1 et 2 et 3

Ce travail expérimental chez le rat attire l'attention sur les effets pro-arythmogènes de l'association HEA-Hypersalé. Ces effets seraient responsables d'une mortalité plus élevée en cas de choc hémorragique.

Small volume7.5% NaCl with 6% dextran-70 or 6% and 10% hetastarch are associated with arrhythmias and death after 60 minutes of severe hemorrhagic shock in the rat in vivo

Letson H et all. DOI:10.1097/TA.0b013e3181e99c63

Conclusions:

Small volumes of 7.5% NaCl led to fewer arrhythmias and a 2.6 times survival beneﬁt over untreated rats, and a partial resuscitation of MAP into the “permissive range.” Dextran-70 or HES in 7.5% NaCl were proarrhythmic and HES led to increased mortality(p 0.05). Because optimal heart function is critical for successful resuscitation, care should be exercised when using dextran-70 or 6 and 10% HESin small volume hypertonic saline solutions for early hypotensive resuscitation.

Commentaires

La stratégie de remplissage vasculaire en conditions de combat est d'initier ce dernier dès que le pouls radial n'est pas perçu et associé à une anomalie de la conscience. Il faut utiliser un soluté salé pur à 7,5% administré en 20 minutes, suivi en cas d'inefficacité de 500 ml d'HEA type et à défaut d'un second soluté hypersalé à 7,5%. Le recours à l'administration d'adrénaline titrée est requis dès la perfusion de la seconde poche.

Cette stratégie résulte d'un compromis entre ce qui est possible en condition tactique et l'état de l'art et des recommandations.

Approfondir

1. La RPC de la SFAR (de1997, un peu ancienne)

2. Les recommandations anglaises

3. Les recommandations américaines

4. Les recommandations européennes pour la prise en charge du traumatisé sévère

Ce travail met en avant l'intérêt d'un dispositif laryngé en préhospitalier. Mais les indications sur lesquelles reposent cette expérience sont représentées par le contrôle des voies aériennes lors d'arrêt cardiaque, de comas toxiques et d'accident vasculaires cérébraux. Ceci ne permet pas d'extrapoler l'emploi de ces dispositifs en traumatologie de guerre.

Clinical paper

The Easytube

for airway management in prehospital emergency medicine

Hichem Chenaitia^a^,^,, Valéry Soulleihet^a, Horace Massa^b, Jacques Bessereau^a, Jeremy Bourenne^c, Pierre Michelet^a and Jean-Pierre Auffray ^a

^a Department of Emergency Medicine and Intensive Care, Timone University Hospital, Marseille, France

^b Department of Anaesthesiology and Intensive Care, Geneva University Hospital, Switzerland

^c Intensive Care Unit, Timone University Hospital, Marseille, France

Received 3 February 2010;

revised 19 April 2010;

accepted 2 June 2010.

Available online 10 July 2010.

Abstract

Background

Securing the airway in emergency is among the key requirements of appropriate prehospital therapy. The Easytube (Ezt) is a relatively new device, which combines the advantages of both an infraglottic and supraglottic airway.

Aims

Our goal was to evaluate the effectiveness and the safety of use of Ezt by emergency physicians in case of difficult airway management in a prehospital setting with minimal training.

Methods

We performed a prospective multi-centre observational study of patients requiring airway management conducted in prehospital emergency medicine in France by 3 French mobile intensive care units from October 2007 to October 2008.

Results

Data were available for 239 patients who needed airway management. Two groups were individualized: the “easy airway management” group (225 patients; 94%) and the “difficult airway management” group (14 patients; 6%). All patients had a successful airway management. The Ezt was used in eight men and six women; mean age was 64 years. It was used for ventilation for a maximum of 150 min and the mean time was 65 min. It was positioned successfully at first attempt, except for two patients, one needed an adjustment because of an air leak, and in the other patient the Ezt was replaced due to complete obstruction of the Ezt during bronchial suction.

Conclusion

The present study shows that emergency physicians in cases of difficult airway management can use the EzT safely and effectively with minimal training. Because of its very high success rate in ventilation, the possibility of blind intubation, the low failure rate after a short training period. It could be introduced in new guidelines to manage difficult airway in prehospital emergency.

Keywords: Easytube; Prehospital emergency medicine; Difficult airway management

Article Outline

Introduction

Material and methods: 2.1. Study design; 2.2. Setting; 2.3. Protocol; 2.4. Data collection and measurements

Results

Discussion

Conclusion

Conflict of interest statement

Supplementary data

References

1. Introduction

Securing the airway in emergency patients is among the key requirements of appropriate prehospital therapy. Endotracheal intubation (ETI) is currently the “gold standard” for airway management in a prehospital setting, but this is a complex technique requiring practice and experience. As failure to secure airway can increase morbidity and mortality within a very short time, and as multiple failed intubation attempts can lead to additional trauma [1], knowledge and availability of alternative procedures are essential for every emergency physician.

The European Resuscitation Council Guidelines for Cardiopulmonary Resuscitation 2005 recommend that tracheal intubation should be attempted only by trained personnel with adequate ongoing experience, and in cases of failure to intubate the trachea using an endotracheal tube (ETT), the Combitube is an acceptable alternative [2].

The Easytube (Ezt, Teleflex Medical Ruesch) is a 0relatively new device (Fig. 1). It is a sterile, disposable airway device, approved by the European Union in 2003 and by the U.S. Food and Drug Administration in 2005. The Ezt is a two-lumen tube with a pharyngeal proximal cuff and a distal cuff. One lumen of the Ezt opens at the distal end and the other lumen serves as a supraglottic ventilation aperture between the two cuffs. It is latex free and available in two sizes to be used in patients with a height of 90–130 cm (size 28 Fr [French]) or over 130 cm (size 41 Fr). The distal end of the Ezt is designed like a standard ETT with a tip diameter of 7.5 mm (size 41 Fr) or 5.5 mm (size 28 Fr). It includes a Murphy eye at its tip. The design of the pharyngeal aperture allows insertion of a flexible fiberoptic bronchoscope, bougie or suction catheter with a maximum external diameter of 3.9 mm into the trachea.

Full-size image (26K)

Fig. 1.

Easytube (EzT; Teleflex Ruesch, Research Triangle Park, NC) 28 Fr for patients with a height of 90–130 cm (left) and EzT 41 Fr for patients greater than 130 cm (right).

It is fairly similar to the Combitube. Both the Combitube and the Ezt can be used as infraglottic or supraglottic airways. They enable sufficient ventilation whether they are inserted into the oesophagus or the trachea [3], [4]and [5]. The Ezt was developed for in-hospital and out-of-hospital use in all patients with anticipated or unanticipated airway difficulties [1], [2], [3], [4] and [5].

The French prehospital Emergency Medical System (EMS) is based on a national phone number (15 or 112). A physician screens each call. In cases of vital distress, a mobile intensive care unit (MICU) consisting of an emergency physician, a nurse and an ambulance driver is sent to the scene within minutes.

The aim of this study was to evaluate the effectiveness and the safety of use of Ezt by emergency physicians in case of difficult airway management in a prehospital setting with minimal training.

2. Material and methods

2.1. Study design

This study was a prospective multi-centre study of patients requiring airway management conducted in a French prehospital EMS (SAMU 13) in the city of Marseille, by 3 French MICUs over a 12-month period.

The primary outcome measurement was airway management success. Our hypothesis was that emergency physicians would be able to successfully perform prehospital airway management using the Ezt in cases of difficult airway management with minimal training.

2.2. Setting

In order to evaluate the Ezt, all emergency physicians used the same algorithm for airway management (Fig. 2). It included 3 MICUs distributed in different parts of the city.

Full-size image (23K)

Fig. 2.

The airway management protocol during the study period. BVM: Bag valve mask; BURP maneuver: backward, upward and rightward pressure maneuver; DI: difficult intubation; DL: direct laryngoscopy; ETI: endotracheal intubation; Ezt: Easytube; ICU: intensive care unit.

Emergency physicians were trained in the use of Ezt on manikins. Ten consecutive successful intubations were required for every physician before beginning the evaluation of Ezt.

The inclusion criteria were: all the patients with a height above 90 cm and an indication for prehospital airway management.

The exclusion criteria were a contraindication to the use of Ezt: patients with a height less than 90 cm, patients suffering from upper airway obstruction, and patients suffering from oesophageal diseases or ingestion of caustic substances.

2.3. Protocol

During the study period, all patients were managed with the same airway management protocol (Fig. 2). Our protocol complies with the guidelines of the French Society of Anaesthesia and Resuscitation (SFAR) and received ethical approval from Marseille University Hospital's Emergency Committee.

The SFAR defines difficult intubation (DI) as more than two failed intubation attempts under direct laryngoscopy with an optimal head position.

We prospectively separated patients into 2 groups: “easy airway management”: less than 2 ETI attempts and “difficult airway management”: more than 2 ETI attempts or use of EZT in accordance with the protocol.

In our study, before ETI we also systematically evaluate predictive signs of DI (short neck, restricted mouthopening <3 cm, estimated thyromental distance <6 cm, morbid obesity with body mass index estimated more than 40 and cervico-facial trauma).

For a patient with vital distress on arrival of the prehospital medical team on-site and after evaluation of the situation, the emergency physician decides if intubation is necessary.

The patients were preoxygenated by Bag–Valve–Mask (BVM) with 100% oxygen for 3 min, except in the case of cardio-respiratory arrest or if there was an immediate indication of intubation.

During airway management, patients were monitored continuously by electrocardiogram, cutaneous pulse oximetry and non-invasive arterial pressure.

A Rapid Sequence Induction (RSI) with etomidate (0.3 mg/kg) and succinylcholine (1 mg/kg) was performed in patients with cardiac activity. Arrest patients were intubated without giving any medications.

If there was no predictive sign of DI, ETI was attempted with an ETT and by a direct laryngoscopy, with or without a stylet.

Whatever the attempted airway management, this is always limited to 40 s.

If ETI failed, ventilation by BVM with 100% oxygen was resumed, or in the event of a predictive sign of DI, an attempt at ETI was recommended but with measures taken to facilitate intubation: place the head in the modified Jackson position or “sniffing position”, if no cervico-facial trauma, bend the tube into a “hockey stick” shape with a stylet and have an assistant perform the BURP (backward upward rightward pressure) maneuver to move the larynx closer to the visual axis for intubation.

If ETI failed again, ventilation by BVM with 100% oxygen was resumed and a further attempt with Ezt was recommended, respecting any contraindications.

If a “cannot intubate, cannot ventilate” situation occurred and as no time could be wasted in further intubation attempts, immediate use of Ezt was allowed because the Combitube and the Ezt are listed as a rescue method in “cannot ventilate–cannot intubate” situations by the American Society of Anaesthesiologists [6].

Laryngoscopic insertion of Ezt is very similar to the use of a standard ETT, and if an ETI by Ezt is finally possible, the patient is ventilated through the transparent lumen.

If ETI is not possible, the tip of the EzT can be inserted into the esophagus under visual guidance with the help of a laryngoscope or blindly.

If it is inserted blindly, the patient's head must be in neutral position. Manually opening the patient's mouthand pressing the tongue gently toward the mandible, the tube is inserted parallel to the frontal axis of the patient until the proximal black ring mark is positioned at the level of the incisors. If the EzT is inserted blindly, the tip is likely to be positioned in the esophagus with a probability of more than 95% [3]. Ventilation of the patient should be performed using a colored lumen, and the transparent lumen can then be used to insert a gastric tube or to drain gastric contents.

The colored pharyngeal proximal cuff and the transparent distal cuff are subsequently inflated with 80 and 10 ml of air, using two pre-filled syringes in the package. Inflation of the pharyngeal cuff occludes theoropharynx and should prevent inhalation of blood or secretions from the oral or nasal cavity. The transparentdistal cuff seals the oesophagus and should prevent inhalation of gastric contents.

Correct insertion of Ezt was defined as efficient ventilation of the patient assessed by three square-wave capnograph traces during manual ventilation, symmetric auscultation with no audible gastric insufflations or air leak.

If all of these methods failed, ventilation by BVM with 100% oxygen was resumed and a “Failed Airway Algorithm” was applied to the patients by performing a cricothyrotomy with the “Quick-Trach Emergency Cricothyrotomy Device.”

After airway management, anaesthesia was maintained with Midazolam (0.1 mg/kg/h) and Fentanyl(1 μg/kg/h). The patients underwent positive pressure ventilation in a pressure-controlled mode; the limit was set at 30 cm H₂O airway pressure; the targeted tidal volume was 7 mL/kg; inspired oxygen concentration (FIO₂) at 1; respiratory rate was set to achieve an End-Tidal CO₂ (ETCO₂) concentration of 35–45 mmHg. The patients were continuously monitored by standard non-invasive measures including electrocardiogram, cutaneous pulse oximetry, non-invasive blood pressure measurement (every 5 min) and capnography.

Subsequently, the patients were rapidly admitted to intensive care unit (ICU). The Ezt was replaced by an ETT in ICU, with an airway exchange catheter as soon as possible.

2.4. Data collection and measurements

The emergency physicians filled the study forms immediately after each airway management. The study form included patient's age and sex, Glasgow coma scale (GCS) score, approximate height (less or more than 130 cm), clinical status and indication for intubation (cardio-respiratory arrest, severe neurological distress, severe respiratory distress or other). The forms were anonymous. Predictive signs of DI (short neck, restricted mouth opening <3 cm, estimated thyromental distance <6 cm, morbid obesity and cervico-facialtrauma) and number of intubation attempts were also noted. Incidents and complications of intubation were reported by means of open-ended questions. All the data were then managed in a computer database.

3. Results

During the study period, 239 patients needed prehospital airway management and no patient was excluded.

These 239 patients were divided into 2 groups: 225 (94%) patients in “easy airway management” and 14 (6%) patients in “difficult airway management”. The characteristics for both groups are illustrated in Table 1.

Table 1. Comparison between easy and difficult airway management groups.

	Easy airway management	Difficult airway management
Patients per group	225 (94%)	14 (6%)
Sex: female/male ratio	78/147	6/8
Mean age [range age]	54 years [16 days to 96 years]	64 years [45–93 years]
Mean initial GCS score	5	4
Mean intervention time of MICU [range time]	72 min [20–145 min]	65 min [25–150 min]
Predictive DI signs	51 (23%)	10 (71%)
Use stylet	39 (17%)	14 (100%)

Scene intervention
At home	108 (48%)	8 (57%)
Outside	45 (20%)	2 (14%)
Hospital or care place	72 (32%)	4 (29%)

Intubations indications
CRA	84 (38%)	8 (57%)
Respiratory distress	36 (16%)	4 (29%)
Neurologic distress	81 (36%)	2 (14%)
Others: voluntary drug poisoning	24 (10%)	0

Intubations complications
Dental trauma	1 (0.4%)	0
Macroscopic inhalation^a	7 (3%)	2 (14%)
Oesophageal intubation^a	13 (6%)	3 (21%)
Selective intubation	12 (5%)	0
Collapse post-intubation	33 (15%)	0
ACR	0	0
Mean intubations attempts	1.25	3
[range attempts]	[1–2]	[2–5]

GCS: Glasgow coma scale; MICU: mobile intensive care unit; DI: difficult intubation; CRA: cardio-respiratory arrest.

^a Only during ETI attempts.

All the patients had successful airway management, and no patient required a surgical airway management. We did not encounter a “cannot ventilate–cannot intubate” situation in our study.

Among the 239 cases of airway management in a prehospital setting, the Ezt was used 14 times. It was used in eight men and six women; the male-to-female ratio was 1.33. The age range was 45–93 years; mean age was 64 years.

The Ezt was used for ventilation for a maximum of 150 min, intervention time by MICUs in prehospital situations was 25–150 min, and the mean time was 65 min.

Only Ezt size 41 Fr was used during the study because no patient in the height range 90–130 (Ezt of size 28 Fr) presented difficult airway management.

The Ezt was positioned successfully at first attempt, except for two patients: one needed an adjustment because of air leaks, and for the other patient, the Ezt was replaced due to a complete obstruction of the Ezt during bronchial suction after aspiration of gastric contents.

Predictive signs of DI were found in 61 patients of the 239 airway management cases; this represents 25% of patients with airway management in prehospital situations. The predictive signs of DI are shown in Table 2. The study shows the presence of predictive signs of DI in 71% of cases of the “difficult airway management” group.

Table 2. Predictive signs of difficult intubation.

Predictive signs of difficult intubation	Numbers (%)
Morbid obesity	26 (42%)
Cervico-facial trauma	16 (26%)
Short neck	11(18%)
Restricted mouth opening <3 cm	7 (12%)
Thyromental distance <6 cm	1 (2%)

Total	61

4. Discussion

A number of previous studies show that the EzT is comparable to the ETT with respect to oxygenation and ventilation, and might even have minor advantages, as the EzT can be inserted slightly more quickly and easily than the ETT [4] and [7].

Our results are in agreement with other studies showing that a short learning period may be sufficient to train emergency physicians since the success rate is high [4] and [7].

In our study, the insertion of the Ezt was successful at the first attempt in all cases. These results are in agreement with other studies carried out which show a very low insertion failure rate [5].

During this study, we noted one specific complication associated with Ezt, to our knowledge never described. This was complete obstruction of the Ezt during bronchial suction after aspiration of gastric contents. The aspiration occurred after 2 failed ETI attempts. The first Ezt was removed and a second Ezt was used without complication.

The main advantages of the Ezt are: shorter insertion time for Ezt than for ETI, better protection against aspiration than a laryngeal mask and the possibility of blind insertion of the Ezt in patients trapped in a sitting position (car crash) [5], [6] and [7].

Unfortunately, in our study, we were unable to assess the time needed to establish an airway for ethical reasons as we were acting in severe emergency cases.

Our difficult intubation rate was 6%, compared with 2.7–12.3% cited in the emergency medicine literature [8],[9], [10], [11], [12] and [13].

Our study showed that prehospital airway difficulties can be predicted in 71% of cases, with easily identifiable predictive signs of DI (morbid obesity, cervico-facial trauma, short neck, restricted mouth opening <3 cm, thyromental distance <6 cm), and we found only 29% unanticipated airway difficulties in prehospital settings.

Our findings suggest that in prehospital emergencies, except for cervico-facial trauma injuries (26% of patients), the most frequent causes of DI are similar to those encountered in clinical practice: morbid obesityand short neck [14].

Rapid evaluation of predictive signs of DI could make airway difficulties possible to anticipate before performing laryngoscopy, to plan alternatives to direct laryngoscopy and to preclude multiple attempts.

However, our study highlights that the stylet is not used enough in French practice, even when there were predictive signs of DI, despite our protocol's recommendations and international guidelines (only 17% of overall ETI and 76% in cases of anticipated airway difficulties).

Nevertheless this prospective observational study had several limitations. No study details optimal training in Ezt use or that Ezt training on manikins is transferable to real patients, thus training in the use of Ezt was not based on evidence-based medicine. Incomplete forms were the most common problem, requiring a supplementary search of the medical files to complete the forms. Selective intubation (no lung expansion visible and absence of sounds during auscultation, reversible situation after moving ETT) was investigated only if it was identified on-site and thus the incidence may have been underestimated in this study. Another limitation of our study is that the data were self-reported by the persons who performed the intubations and hence the number of attempts or complications may have been underestimated.

5. Conclusion

It is essential that emergency physicians receive rigorous training in difficult airway management as well as how to investigate predictive signs of DI in order to plan alternatives to ETI and to avoid potential complications that may arise with several attempts.

Despite the wide range of available techniques for the management of DI, not all are suitable for use in prehospital emergency airway management. The Ezt may be recommended because of the very high success rate of ventilation and the possibility of blind intubation. The low failure rate after a short training period demonstrates that it is easy to use and has a steep learning curve.

Clinical evaluations of the Ezt in prehospital situations are scarce, but these results show that emergency physicians with minimal training, in cases of difficult airway management and in prehospital emergency medicine, can use the EzT safely and effectively. It could be proposed as the first-line alternative technique in difficult airway management in prehospital.

Protection des voies aériennes en médecine d’urgence

Journal Européen des Urgences (2010) 23, 44—56

X. Combes, P. Jabre, F. Soupizet

Le résumé

Le contrôle des voies aériennes des patients présentant une détresse vitale est très souvent nécessaire en médecine d’urgence. L’intubation orotrachéale est la technique de référence pour le contrôle des voies aériennes. En dehors du cadre de la réanimation de l’arrêt cardiaque, l’intubation trachéale doit être reéalisée sur un patient sédaté et curarisé selon la technique d’intubation en séquence rapide. L’intubation en urgence est une intubation à risques. L’inhalation pulmonaire et les épisodes de désaturation artérielle profonde sont les deux complications les plus fréquemment associées à ce geste. En médecine d’urgence, l’intubation difficile, rarement prévisible, est plus fréquente qu’au bloc opératoire. La prise en charge de

l’intubation difficile survenant dans le cadre de la médecine d’urgence repose sur l’utilisation de techniques alternatives efficaces. Ces techniques doivent être utilisées selon un algorithme précis. Les mandrins longs béquillés et le masque laryngé d’intubation de type Fastrach TM permettent de résoudre la majorité des cas d’intubation difficile. En cas d’échec de ces deux techniques, une cricothyroïdotomie permettant un abord trachéal direct doit être réalisée chez les patients impossibles à ventiler.

Morceaux choisis

1. On considère qu’un médecin exerçant en SMUR intube annuellement de 15 à 20 patients. Ces chiffres sont à mettre en parallèle avec les données disponibles pour l’activité anesthésique nationale où environ trois millions de patients sont intubés tous les ans au bloc opératoire par des médecins anesthésistes qui intubent chacun en moyenne plus de 300 patients par an.

Un minimum de 40 intubations pour apprendre l'intubation est nécessaire et 20 par an sont nécessaires pour entretenir cette compétence. Cela signifie que la maîtrise de l'abord des VAS est l'objectif principal de la formation continue du médecin d'unité de telle sorte qu'il soit toujours en capacité de faire face à une obstruction des VAS en condition de combat.

2. Les dispositifs laryngés sont probablement plus faciles à insérer pour des opérateurs non médecins que la sonde d’intubation. Les deux problèmes majeurs rencontrés lors de l’utilisation de ce type de matériel sont le risque d’inhalation pulmonaire et le risque de perforation œsophagienne. En effet, ces dispositifs n’assurent pas une protection complète des voies aériennes en cas de vomissement et le risque d’inhalation est alors réel. Plusieurs cas de déchirure du tiers supérieur de l’œsophage ont été rapportés lors de l’utilisation du Combitube^®, liés à la surpression régnant dans le ballonnet œsophagien de ce dispositif.

3. En médecine préhospitalière, les circonstances font que très souvent les patients qui nécessitent une intubation en urgence sont pris en charge alors qu’ils sont allongés sur le sol. L’intubation d’un patient au sol présente quelques difficultés particulières. L’opérateur est en effet dans une position le plus souvent pénible pour réaliser son geste et l’intubation est rendue plus difficile. Une technique de positionnement de l’opérateur visant à limiter les difficultés d’intubation a été décrite récemment. Elle consiste à positionner la personne qui va intuber en décubitus latéral. Dans cette position, l’axe visuel de l’opérateur est abaissé et la visualisation glottique, indispensable pour réaliser l’intubation, est rendue beaucoup plus aisée.

4. Parmi les dispositifs laryngés utilisables en préhospitalier, il faut choisir le FASTRACH car son emploi est documenté et qu'il permet l'intubation orotrachéale.

5. La cricothyroïdotomie représente la technique ultime de contrôle des voies aériennes proposée dans le cas où l’intubation et la ventilation du patient restent impossibles malgré l’utilisation des autres techniques alternatives que sont les mandrins et les dispositifs supraglottiques. ......Cette technique est de réalisation très rapide et permet une ventilation efficace dans plus de 95 % des cas.
6. Un algorithme

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

Bernd A. Leidel^a^,^c^,^,, Chlodwig Kirchhoff^b, Volker Braunstein^b, Viktoria Bogner^b, Peter Biberthaler^band Karl-Georg Kanz^b

Resuscitation
Volume 81, Issue 8, August 2010, Pages 994-999

PREMIER POINT: Le BIG est aussi efficace que l'EZ-IO

Table 2. Success rates on first attempt and procedure times of the two different intraosseous devices BIG and EZ-IO for vascular access in adult emergency patients under resuscitation were not significantly different.

	Overall (n = 40)	BIG (n = 20)	EZ-IO (n = 20)	p (BIG versus EZ-IO)
Success rate on first attempt (%)	34/40 (85)	16/20 (80)	18/20 (90)	0.66
95% CI	73.9–96.1%	62.5–97.5%	76.9–100%

Mean procedure time ± SD (min)	2.0 ± 0.9	2.2 ± 1.0	1.8 ± 0.9	0.27
95% CI	1.7–2.3 min	1.7–2.6 min	1.4–2.2 min

Procedure time, min–max (min)	1.0–4.0	1.0–4.0	1.0–3.0

SECOND POINT: Le BIG une fois sur 2 en HUMERAL

Table 1. Patient characteristics: distribution of gender, age, obesity, trauma and insertion site in adult emergency patients under resuscitation were not significantly different between the two applied different intraosseous devices BIG and EZ-IO for vascular access.

	Overall (n = 40)	BIG (n = 20)	EZ-IO (n = 20)
Gender male (%)	27/40 (68)	13/20 (65)	14/20 (70)
Age ± SD (years) min–max (years)	48 ± 21 18–87	53 ± 22 18–87	43 ± 18 18–79
Obesity BMI > 30 kg/m² (%)	7/40 (18)	3/20 (15)	4/20 (20)
Trauma (%)	29/40 (73)	15/20 (75)	14/20 (70)
Insertion site humeral (%)	22/40 (55)	11/20 (55)	11/20 (55)

TROISIEME POINT: Le BIG : Des échecs en tibial, des diifcultés pour sortir le mandrin à la main

In all four unsuccessful attempts with the BIG, the cannula did not penetrate the bone cortex, probably due to incorrect insertion site in three patients and excessive overlying soft tissue in one patient. All four unsuccessful attempts were tibial. In five patients the stylet was stuck within the cannula and could only be removed with a clamp. After removal of the stylet the administration of drugs and fluids through the cannula was possible without further complications and the IO insertion deemed successful.

Two unsuccessful attempts with the EZ-IO failed because of extravasation at the humeral head insertion site, probably due to incorrect insertion site and excessive overlying soft tissue.

Other technical problems like bending and breaking of the cannula or further relevant complications, likeinfection, extravasation, compartment syndrome, and cannula dislodgment or bleeding were not observed.

ICI

Mettez cela en perspective avec les conditions de combat

NICE has issued preliminary recommendations on the pre-hospital initiation of fluid replacement therapy in trauma for consultation. The guidance covers the management of adults with trauma injury in whom there is evidence of obvious or probable blood loss. It does not cover the management of isolated closed head injury.

In summary:

1. It is recommended that in the pre-hospital management of adults with trauma injuries, intravenous fluid (IV fluid) should not be administered if a radial pulse can be felt (or, for penetrating torso injuries, if a central pulse can be felt).

2. In the absence of a radial pulse (or a central pulse for penetrating torso injuries), it is recommended that IV fluid in boluses of no more than 250 ml should be administered, followed by reassessment until a radial (or central) pulse is palpable.

3. The administration of IV fluid should not delay transportation to hospital, but when given in accordance with 2 above, administration may take place en route to hospital.

4. It is recommended that crystalloid solutions should normally be administered in the pre-hospital setting.

5. There is inadequate evidence, and a lack of professional consensus, on which to base recommendations on the pre-hospital use of IV fluid in children with trauma injury. However, it is recommended that the general principles for IV fluid administration in children should be based on those recommended for adults. Thus, in children considered to be at risk of hypovolaemia, IV fluids should be administered in aliquots with frequent re-assessment of the child's physiological state and transfer to hospital should not be delayed.

6. It is recommended that only paramedics or other healthcare professionals who have been appropriately trained in advanced life-support techniques and pre-hospital care should administer IV fluid therapy to trauma patients in the pre-hospital setting and that training should incorporate the above recommendations.

Une publication récente met à nouveau en garde contre le recours immodéré aux solutés colloïdes pour le remplissage vasculaire. Bien qu'employé en routine les colloïdes ne sont pas dénués d'effets secondaires et leur intérêt est remis en question. On rappelle que le soluté chois pour équiper la trousse individuelle du combattant est un flacon de 250 ml de sérum salé à 7.5%, choix dicté par l'excellent compromis efficacité en terme de remplissage, anti-oedémateux cérébral et poids.

L'article est le suivant:

The Efficacy and Safety of Colloid Resuscitation in the Critically Ill

Christiane S. Hartog, MD, Michael Bauer, MD, and Konrad Reinhart, MD

(Anesth Analg 2011;112:156 –64)

Despite evidence from clinical studies and meta-analyses that resuscitation with colloids or crystalloids is equally effective in critically ill patients, and despite reports from high-quality clinical trials and meta-analyses regarding nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of hydroxyethyl starch (HES) solutions, colloids remain popular and the use of HES solutions is increasing worldwide. We investigated the major rationales for colloid use, namely that colloids are more effective plasma expanders than crystalloids, that synthetic colloids are as safe as albumin, that HES solutions have the best risk/benefit profile among the synthetic colloids, and that the third-generation HES 130/0.4 has fewer adverse effects than older starches. Evidence from clinical studies shows that comparable resuscitation is achieved with considerably less crystalloid volumes than frequently suggested, namely, 2-fold the volume of colloids.

Albumin is safe in intensive care unit patients except in patients with closed head injury. All synthetic colloids, namely, dextran, gelatin, and HES have dose-related side effects, which are coagulopathy, renal failure, and tissue storage. In patients with severe sepsis, higher doses of HES may be associated with excess mortality. The assumption that third-generation HES 130/0.4 has fewer adverse effects is yet unproven. Clinical trials on HES 130/0.4 have notable shortcomings.

Mostly, they were not performed in intensive care unit or emergency department patients, had short observation periods of 24 to 48 hours, used cumulative doses below 1 daily dose limit (50 mL/kg), and used unsuitable control fluids such as other HES solutions or gelatins.

In conclusion, the preferred use of colloidal solutions for resuscitation of patients with acute hypovolemia is based on rationales that are not supported by clinical evidence. Synthetic colloids are not superior in critically ill adults and children but must be considered harmful depending on the cumulative dose administered. Safe threshold doses need to be determined in studies in high-risk patients and observation periods of 90 days. Such studies on HES 130/0.4 are still lacking despite its widespread and increasing use. Because there are safer and equally effective alternatives in the form of crystalloids, use of synthetic colloids should be avoided except in the context of clinical studies.

Nous contacter/Signaler un lien perdu: citera69@mailo.com

A lire

Echographie

Protocoles

Poster

Médecine de l'avant

Fiches mémento

Aides cognitives

31/12/2010

26/12/2010

23/12/2010

21/12/2010

17/12/2010

14/12/2010

Advanced airway management--a medical emergency response team perspective.

Abstract

12/12/2010

11/12/2010

06/12/2010

Clinical paper

Abstract

Background

Aims

Methods

Results

Conclusion

Article Outline

1. Introduction

2. Material and methods

2.1. Study design

2.2. Setting

2.3. Protocol

2.4. Data collection and measurements

3. Results

4. Discussion

5. Conclusion

04/12/2010