Alternative à l'intubation; La coniotomie chirurgicale

Il existe un grand débat concernant les alternatives à l'intubation préhospitalière. Si les dispositifs laryngés apparaissent une alternative du fait de taux d'insertion satisfaisant en particulier le tube KING LT, il n'en demeure toujours pas moins qu'il ne représente toujours pas une solution réelle en conditions de combat du fait de la nécessité de réaliser une anesthésie générale, de l'absence de protection contre le risque d'inhalation, et de limitations importantes en terme de ventilation (pression et déplacement de tube pendant le transport). Ces dispositifs sont par ailleurs relativement volumineux. La recommandation en condition de combat est de privilégier la coniotomie chirurgicale sous AL. 

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Prehosp Emerg Care. 2010 Oct-Dec;14(4):515-30.

A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates.

Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW.

Emergency Medical Care Program, 122 Moore Building, Western Carolina University, Cullowhee, NC 28723, USA. [e-mail]

Abstract

BACKGROUND: Airway management is a key component of prehospital care for seriously ill and injured patients. Oral endotracheal intubation (OETI) is the definitive airway of choice in most emergency medical services (EMS) systems. However, OETI may not be an approved skill for some clinicians or may prove problematic in certain patients because of anatomic abnormalities, trauma, or inadequate relaxation. In these situations alternative airways are frequently employed. However, the reported success rates for these devices vary widely, and established benchmarks are lacking.

OBJECTIVE: We sought to determine pooled estimates of the success rates of alternative airway devices (AADs) and needle cricothyrotomy (NCRIC) and surgical cricothyrotomy (SCRIC) placement through a meta-analysis of the literature.

METHODS: We performed a systematic literature search for all English-language articles reporting success rates for AADs, SCRIC, and NCRIC. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique were calculated using a random-effects meta-analysis model.

RESULTS: Of 2,005 prehospital airway titles identified, 35 unique studies were retained for analysis of AAD success rates, encompassing a total of 10,172 prehospital patients. The success rates for SCRIC and NCRIC were analyzed across an additional 21 studies totaling 512 patients. The pooled estimates (and 95% confidence intervals [CIs]) for intervention success across all clinicians and patients were as follows: esophageal obturator airway-esophageal gastric tube airway (EOA-EGTA) 92.6% (90.1%-94.5%); pharyngeotracheal lumen airway (PTLA) 82.1% (74.0%-88.0%); esophageal-tracheal Combitube (ETC) 85.4% (77.3%-91.0%); laryngeal mask airway (LMA) 87.4% (79.0%-92.8%); King Laryngeal Tube airway (King LT) 96.5% (71.2%-99.7%); NCRIC 65.8% (42.3%-83.59%); and SCRIC 90.5% (84.8%-94.2%).

CONCLUSIONS: We provide pooled estimates for prehospital AAD, NCRIC, and SCRIC airway interventions. Of the AADs, the King LT demonstrated the highest insertion success rate (96.5%), although this estimate is based on limited data, and data regarding its ventilatory effectiveness are lacking; more data are available for the ETC and LMA. The ETC, LMA, and PTLA all had similar-but lower-success rates (82.1%-87.4%). NCRIC has a low rate of success (65.8%); SCRIC has a much higher success rate (90.5%) and should be considered the preferred percutaneous rescue airway.

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Pour approfondir (1) (2) (3)

 

Intubation préhospitalière: Comment ?

 

On peut intuber en pré-hospitalier sans anesthésie (sous AL de glotte) mais c'est mieux avec des agents de sédation et encore mieux avec un protocole d'intubation en séquence rapide. L'intubation nasotrachéale: C'est moins bien, voire sujet à caution.

 

Prehosp Emerg Care. 2010 Jul-Sep;14(3):377-401.

A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates.

Hubble MW, Brown L, Wilfong DA, Hertelendy A, Benner RW, Richards ME.

Emergency Medical Care Program, Western Carolina University, Cullowhee, North Carolina 28723, USA. [e-mail]

Abstract

BACKGROUND: Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking.

OBJECTIVE: We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature.

METHODS: We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression.

RESULTS: Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%-89.4%); OETI for non-cardiac arrest patients: 69.8% (50.9%-83.8%); DFI 86.8% (80.2%-91.4%); and RSI 96.7% (94.7%-98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%-95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%-83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year.

CONCLUSIONS: We provide pooled estimates of placement success rates for prehospital airway interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure.

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Pour approndir (1) (2) (3)

 

 

 

 

 

 

 

 

 

"Scoop and run" or "stay and play"

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Tourniquet: Un algorithme

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Coniotomie: Avec un guide !

La coniotmie ou cricothyrotomie est unetechnique essentielle à maîtriser pour une prise en charge optimale des blessés de la face présentant une obstruction des voies aériennes ( le A du SAFE ABC MARCHE). ICI vous est présenté une technique qu'il faut connaître.

 

Contrôle préhospitalier des hémorragies externes

L'arrêt des hémorragies fait appel à la mise en oeuvre d'un ensemble de moyens représentés par la compression directe des plaies, la mise en place de pansements et de bandage compressifs, la rembourrage de plaie, l'emploi de pansements hémostatiques et la pose de garrrôts. (lire ce document)