Intubation préhospitalière: Oui, mais mieux vaut être pratiquant

Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians

Lockey D. et Al. British Journal of Anaesthesia 113 (2): 220–5 (2014)

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L'idée globale de cet article est que concernant la gestion des voies aériennes en préhospitalier, plus on est pratiquant et plus les situations de gestion difficile sont moins fréquentes, mais que le recours à un abord chirurgical reste une éventualité à laquelle se préparer. Dans ce travail, ce recours est particulièrement fréquent dans les traumas de la face et chez les brûlés.

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Background. Effective airway management is a priority in early trauma management. Data on physician pre-hospital tracheal intubation are limited; this study was performed to establish the success rate for tracheal intubation in a physician-led system and examine the management of failed intubation and emergency surgical cricothyroidotomy in pre-hospital trauma patients. Failed intubation rates for anaesthetists and non-anaesthetists were compared.

Methods. A retrospective database review was conducted to identify trauma patients undergoing pre-hospital advanced airway management between September 1991 and December 2012. The success rate of tracheal intubation and the use and success of rescue techniques were established. Success rates of tracheal intubation by individuals and by speciality were recorded.

Results. The doctor–paramedic team attended 28 939 patients; 7256 (25.1%) required advanced airway management. A surgical airway was performed immediately, without attempted laryngoscopy, in 46 patients (0.6%). Tracheal intubation was successful in 7158 patients (99.3%). Rescue surgical airways were performed in 42 patients, seven had successful insertion of supraglottic devices, and two patients had supraglottic device insertion and a surgical airway. One patient breathed spontaneously with bag-valve-mask support during transfer. All rescue techniques were successful. Non-anaesthetists performed 4394 intubations and failed to intubate in 41 cases (0.9%); anaesthetists performed 2587 intubations and failed in 11 (0.4%) (P¼0.02).

Conclusions. This is the largest series of physician pre-hospital tracheal intubation; the success rate of 99.3% is consistent with other reported data. All rescue airways were successful. Non-anaesthetists were twice as likely to have to perform a rescue airway intervention than anaesthetists. Surgical airway rates reported here (0.7%) are lower than most other physician-led series (median 3.1%, range 0.1–7.7%).