Airway en préhospitalier US: Plus tube que dispositif glottique

An update on out-of-hospital airway management practices in the United States

Diggs LA. et Al. Resuscitation. 2014 Mar 15. pii: S0300-9572

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Ce document fait le point sur la pratique préhospitalière US. Cette dernière est faite avant tout d'intubation et la prudence est de mise concernant les performances réelles des dispositifs supra-glottiques avec lesquels (excepté le tube de king) les résultats sont moins bons.

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OBJECTIVE: We characterized out-of-hospital airway management interventions, outcomes, and complications using the 2012 NEMSIS Public-Release Research Data Set containing almost 20 million Emergency Medical Services activations from 40 states and two territories. We compared the outcomes with a previous study that used 2008 NEMSIS data containing 16 states with 4 million EMS activations.

METHODS:

Patients who received airway management interventions including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and surgical) were identified. Using descriptive statistics, airway management success and complications were examined in the full cohort and key subsets including cardiac arrest, non-arrest medical, non-arrest injury, children<10 years, children 10-19 years, rapid sequence intubation (RSI), population setting, US census region, and US census division.

RESULTS:

Among 19,831,189 EMS activations, there were 74,993 ETIs, 21,990 alternate airways, and 1332 cricothyroidotomies. ETI success rates were: overall 63,956/74,993 (85.3%; 95% CI: 85.0-85.5), cardiac arrest 33,558/39,270 (85.5%), non-arrest medical 12,215/13,611 (89.7%), non-arrest injury (90.1%), children<10 years 2069/2468 (83.8%), children 10-19 years 1647/1900 (86.7%), adults>19 years 58,965/69,144 (85.3%), and rapid sequence intubation 5265/5658 (93.1%). Major complications included bleeding 677 (4.4 per 1000 interventions), vomiting 1221 (8 per 1000 interventions), esophageal intubation immediately detected 874 (5.7 per 1000 interventions), and esophageal intubations other 219 (1.4 per 1000 interventions).

CONCLUSIONS:

 

Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting. Only selected emergency medical procedures have proved to be safe and effective. The safety and efficacy profile of ETI has been challenged in the last ten years. Intubation has been the standard of care in the United States for more than thirty years and is regarded as one of the most important EMS procedures. In this study, we retrospectively examined the largest aggregate of EMS data currently available and observed low out-of-hospital ETI success rates.

ETI is a complex procedure requiring skilled choreography and numerous critical decisions and actions. In the absence of qualified personnel, or if ETI proves problematic, alternate airways are commonly employed. As more EMS systems embrace alternate airway devices in lieu of ETI, it is important to have a clear appreciation of the true success rates of airway procedures using these devices across a variety of patient characteristics and clinical settings. This study examined the most commonly used alternate airway devices including the Combitube, Esophageal Obturator Airway, Laryngeal Mask Airway, King Laryngeal Tube, and cricothyroidotomy and observed very low alternate airway success rates in the largest population sample to date. Alternate airway success rates were substantially lower than ETI success rates except for the King LT.