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07/04/2014

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).

PreHospIntub.jpg

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.

| Tags : airway, intubation

01/04/2014

Bougie d'intubation: Pas toutes égales

 

img_1008.jpg

Bougie-related airway trauma: dangers of the hold-up sign

Marson BA et Al. Anaesthesia 2014, 69, 219–223

Le bon positionnement d'un mandrin d'intubation est confirmé parles sensations de ressaut quand l'extrémité de ce dernier franchit les anneaux trachéaux et par le blocage de ce dernier dans l'arbre bronchique. Ce dernier signe est appelé "the hold up sign" par les anglo-saxons. Ce blocage confirme que le mandrin n'est pas intra-oesophagien auquel cas il n'existerait pas. Cette publication attire l'attention sur le danger potentiel de traumatisme trachéal.

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The bougie is a popular tool in difficult intubations. The hold-up sign is used to confirm tracheal placement of a bougie. This study aimed to establish the potential for airway trauma when using this sign with an Eschmann reusable bougie or a Frova single-use bougie. Airways were simulated using a manikin (hold-up force) and porcine lung model (airway perforation force). Mean (SD) hold-up force (for airway lengths over the range 25–45 cm) of 1.0 (0.4) and 5.2 (1.1) N were recorded with the Eschmann and Frova bougies, respectively (p < 0.001). The mean (SD) force required to produce airway perforation was 0.9 (0.2) N with the Eschmann bougie and 1.1 (0.3) N with the Frova bougie (p = 0.11). It is possible to apply a force at least five times greater than the force required to produce significant trauma with a Frova single-use bougie. We recommend that the hold-up sign should no longer be used with single-use bougies. Clinicians should be cautious when eliciting this sign using the Eschmann re-usable bougie.

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Il existe d'autres bougies que celle d'eschmann et de Frova comme l'Introes pocket bougie ou la traffic light bougie. Cette dernière apparaît très intéressante car permettant de limiter la longueur de mandrin inséré dans la trachée et partant le risque de perforation trachéale.

| Tags : intubation

29/01/2014

Trauma ballistique de la face: 1/3 nécessitent un airway sécurisé

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: Results of an 11-year multi-institutional study of 720 patients

 

Shackford et All. J Trauma Acute Care Surg. 2014;76: 347-352

BACKGROUND:

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.

METHODS:

We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.

RESULTS:

From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001).

CONCLUSION:

GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.

 

| Tags : airway

28/01/2014

Airway préhospitalier: L'approche israélienne

Prehospital intubation success rates among Israel Defense Forces providers: Epidemiologic analysis and effect on doctrine

Katzenell U. et All. J Trauma Acute Care Surg. 2013 Aug;75(2 Suppl 2):S178-83

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Un taux de succès somme toute acceptable mais par la répétition des essais. Un algorithme simple puisqu'il ne fait appel qu'à 3 techniques: l'intubation, la coniotomie et la ventilation au masque. Les auteurs recommandent de ne pas se tromper de combat et d'éviter de rentrer dans celui de l'intubation si le contexte opérationnel est très présent. Au final assez proche de ce qui est prôné dans la procédure du sauvetage au combat.

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BACKGROUND:

Advanced airway management is composed of a set of vital yet potentially difficult skills for the prehospital provider, with widely different clinical guidelines. In the military setting, there are few data available to inform guideline development. We reevaluated our advanced airway protocol in light of our registry data to determine if there were a preferred maximum number of endotracheal intubation (ETI) attempts; our success with cricothyroidotomy (CRIC) as a backup procedure; and whether there were cases where advanced airway interventions should possibly be avoided.

METHODS:

This is a descriptive, registry-based study conducted using records of the Israel Defense Forces Trauma Registry at the research section of the Trauma and Combat Medicine Branch, Surgeon General's Headquarters. We included all casualties for whom ETI was the initial advanced airway maneuver, and the number of ETI attempts was known. Descriptive statistics were used.

RESULTS:

Of 5,553 casualties in the Israel Defense Forces Trauma Registry, 406 (7.3%) met the inclusion criteria. Successful ETI was performed in 317 casualties (78%) after any number of ETI attempts; an additional 46 (11%) underwent CRIC, and 43 (11%) had advanced airway efforts discontinued. ETI was successful in 45%, 36%, and 31% of the first, second, and third attempts, respectively, with an average of 28% success over all subsequent attempts. CRIC was successful in 43 (93%) of 46 casualties in whom it was attempted. Of the 43 casualties in whom advanced airway efforts were discontinued, 29 (67%) survived to hospital discharge.

IDF Intubation.jpg

CONCLUSION:

After the first ETI attempt, success with subsequent attempts tended to fall, with minimal improvement in overall ETI success seen after the third attempt. Because CRIC exhibited excellent success as a backup airway modality, we advocate controlling the airway with CRIC if ETI efforts have failed after two or three attempts. We recommend that providers reevaluate whether definitive airway control is truly necessary before each attempt to control the airway.

07/12/2013

Rupture cricotrachéale: Que faire ?

Cricotracheal Separation after Gunshot to the Neck: Report of a Survivor with Recovery of Bilateral Vocal Fold Function.

Vivero RJ et Al. http://dx.doi.org/10.1016/j.jemermed.2013.08.090

Il s'agit d'une éventualité rarissime mais cette observation montre qu'en situation d'isolement extrême il peut être possible d'agir si la partie distale est visible. Encore faut il connaître l'existence de cette conduite à tenir.

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Initial appropriate airway management is imperative to improve survival. Numerous case reports in the literature demonstrate incidental findings of airway injury after routine workup of the patient or the advent of ominous clinical findings (1,2) . At this stage in patient management, it can become difficult to adequately secure the airway, which places the patient at increased risk. A careful physical examination is therefore critical, with fiberoptic laryngoscopy used, as necessary, in the stable patient. A CT scan can be a useful adjunct in the clinical workup, but it should not be relied upon solely, as it can be inconclusive (3) . When cricotracheal separation is identified and the patient is stable, the airway should be secured surgically in the operating room or trauma bay. The proximal stump of the airway should be grasped and secured with a clamp, and then an awake tracheotomy performed (under local anesthesia if possible) distal to the injury. In the event that the patient is unstable or that intubation fails, the distal stump of the trachea should be identified either visually or by palpation. The stump of trachea should then be grasped with a clamp and pulled superficially (out of the wound toward the skin surface), and an appropriately sized endotracheal tube is placed as a temporary measure and secured. The clamp should not be removed from the airway, as the distal tracheal stump can retract into the mediastinum. The patient should then be taken to the operating room emergently for formal tracheotomy or maturation of the airway tracheostoma. In general, cricothyrotomy should not be performed, as this is usually proximal to the site of airway separation.

| Tags : airway

06/11/2013

Voies aériennes: Avant tout une histoire de communication

Airway management: judgment and communication more than gadgets

Donati F. Can J Anesth/J Can Anesth (2013) 60:1035–1040

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Un éditorial publié à l'occasion de la sortie des nouvelles recommandations canadiennes sur l'intubation difficile (1 et 2). Plein de on sens et de pragmatisme et au final de rigueur scientifique dans ce document qui insiste sur le facteur humain et non le facteur matériel. . Les points essentiels sont 

1.   le maintien de l’oxygènation est proposé comme objectif ultime de toute manœuvre au niveau des voies aériennes

Non pas 

"cannot intubate cannot ventilate"

mais  

"cannot intubate cannot oxygenate"

2.  Malgré la popularité croissante et l’utilisation répandue des dispositifs supraglottiques, l’intubation trachéale demeure l’étalon or et la méthode préférée pour une prise en charge stable des voies aériennes.

3.  La vidéolaryngoscopie n’est pas présentée comme la solution universelle à tous les problèmes liés aux voies aériennes

4. Le nombre de tentatives, quelle que soit la technique d’intubation ou la position, devrait se limiter à trois même si n’existe aucune donnée probante solide appuyant un tel énoncé.

5.  Même si il existe des données probantes selon lesquelles un accès chirurgical aux voies aériennes chirurgicales ne sauve pas toujours des vies, le groupe recommande d’essayer d’obtenir un accès chirurgical aux voies aériennes lorsque tous les autres types de tentative échouent.

| Tags : airway, oxygène

29/10/2013

Intubation en préhospitalier : intérêt des nouvelles techniques

IOT difficile et les nouveaux outils en situation d’urgence ( où en est-on ? )

Les procédures validées

Combes X et All. Urgences - 2013

Points essentiels 

■ L’intubation en séquence rapide est la technique de sédation validée pour faciliter l’intubation en situation d’urgence.

■ La préoxygénation peut être réalisée par VNI chez le patient coopérant.

■ Les lames de laryngoscopes en plastique ne doivent pas être utilisées.

■ L’utilisation du mandrin long béquillé est parfaitement validée en situation d’urgence en cas d’intubation difficile sans difficulté de ventilation associées.

■ Le masque laryngé d’intubation Fastrach® est le dispositif de ventilation le plus utile en situation d’urgence.

■ Les vidéolaryngoscopes ne sont pas encore validées pour la prise en charge de l’intubation difficile en situation d’urgence.

 

■ Les dispositifs de cricothyroïdotomiee basée sur la technique de Seldinger sont à privilégier en situation d’urgence

| Tags : airway, intubation

29/05/2013

Vidéo laryngoscopie: Du bien, on n'est pas étonné

voies aériennes

Anesth  Analg 2013;XX:XX–XX 

BACKGROUND:The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators.

METHODS:We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension.

voies aériennes

RESULTS:There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL. 

CONCLUSIONS:UEI using a VL as the primary device improved intubation success anddecreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.

| Tags : intubation, airway

03/03/2013

Mieux voir pour mieux intuber. Un moyen simple surtout si on débute

Retrograde Light-guided Laryngoscopy for Tracheal Intubation. Clinical Practice and Comparison with Conventional Direct Laryngoscopy

Anesthesiology 2013; 118:XXX–XXX doi: 10.1097/ALN.0b013e31828877c0.

L'intubation orotrachéale nécessite un apprentissage réel. Une cinquantaine de procédures réussies sont nécessaires pour pouvoir considérer avoir la maîtrise de ce geste. De nombreux dispositifs permettent d'augmenter le taux de réussite (bougie, stylets lumineux, dispositifs laryngés, fibroscopie, vidéolaryngoscope). Ces dernières sont cependant onéreuses et pas forcément toujours disponibles. L'illumination transtrachéale et rétrograde du plan glottique pourrait avoir une certaine utilité en améliorant la visualisation de l'orifice glottique.

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Compared with DL, the success rate was greater in the RLGL group for all five intubations (72% vs. 47%; rate difference, 25%; 95% CI [11.84–38.16%], P < 0.001). This was associated with a shorter time to glottic exposure (median [25th and 75th percentile]; 27 [15; 42] vs. 45 [30; 73] s, P < 0.001), shorter intubation time (66 [44; 120] vs. 120 [69; 120] s, P < 0.001), and decreased throat soreness (mean ± SD; visual analog scale, 2.1 ± 0.9 vs. 3.7 ± 1.0 cm, P = 0.001) in the RLGL group compared to the DL group.

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EclairageRetro.jpeg

| Tags : intubation, airway

24/02/2013

Intubation: Encore une étude POUR

Comparison of Neurological Outcome between Tracheal Intubation and Supraglottic Airway Device Insertion of Out-of-hospital Cardiac Arrest Patients: A Nationwide, Population-based, Observational Study

J Emerg Med. 2013 Feb;44(2):389-97

BACKGROUND:

The effect of prehospital use of supraglottic airway devices as an alternative to tracheal intubation on long-term outcomes of patients with out-of-hospital cardiac arrest is unclear.

STUDY OBJECTIVES:

We compared the neurological outcomes of patients who underwent supraglottic airway device insertion with those who underwent tracheal intubation.

METHODS:

We conducted a nationwide population-based observational study using a national database containing all out-of-hospital cardiac arrest cases in Japan over a 3-year period (2005-2007). The rates of neurologically favorable 1-month survival (primary outcome) and of 1-month survival and return of spontaneous circulation before hospital arrival (secondary outcomes) were examined. Multiple logistic regression analyses were performed to adjust for potential confounders. Advanced airway devices were used in 138,248 of 318,141 patients, including an endotracheal tube (ETT) in 16,054 patients (12%), a laryngeal mask airway (LMA) in 34,125 patients (25%), and an esophageal obturator airway (EOA) in 88,069 patients (63%).

RESULTS:

The overall rate of neurologically favorable 1-month survival was 1.03% (1426/137,880). The rates of neurologically favorable 1-month survival were 1.14% (183/16,028) in the ETT group, 0.98% (333/34,059) in the LMA group, and 1.04% (910/87,793) in the EOA group. Compared with the ETT group, the rates were significantly lower in the LMA group (adjusted odds ratio 0.77, 95% confidence interval [CI] 0.64-0.94) and EOA group (adjusted odds ratio 0.81, 95% CI 0.68-0.96).

vas, intubation

CONCLUSIONS:

Prehospital use of supraglottic airway devices was associated with slightly, but significantly, poorer neurological outcomes compared with tracheal intubation, but neurological outcomes remained poor overall.

| Tags : airway, intubation

20/08/2012

L'intubation mieux qu'un dispositif supraglottique

Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest

Wang HE et all. Resuscitation 83 (2012) 1061–1066

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Lors de la prise en charge préhospitalière d'un arrêt cardiaque il vaut mieux intuber que mettre en place un dispositif laryngé. Les conclusions de ce travail interpellent car elles vont à l'encontre de certaines propositions d'emploi de dispositifs laryngés pour le contrôle préhospitalier des voies aériennes. 

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Objective

To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA.

Methods

We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out-of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders.

Results

Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-h survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16).

 

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Conclusions

In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.

17/07/2012

Dispositifs laryngés: Toujours pas validés !

Un retour d'expérience à méditer qui met en évidence que plus de la moitié des dispositifs laryngés posés en préhospitalier ne sont pas positionnés de manière correcte.

http://www.medicalsci.com/files/f2f__10__king_ltd_-_afmes...

KingLT.jpg

Un document faisant le point sur les divers dispositifs laryngés est accessible ici 

| Tags : airway

18/04/2012

Conférence Experts: Intubation difficile

http://citerahiadesgenettes.hautetfort.com/list/intubatio...

| Tags : intubation

Intubation: Une vision en secours en montagne

http://www.secours-montagne.fr/IMG/pdf/techniques_d_IOT_G...

09/12/2011

Intubation: Une formation minimale

A Critical Reassessment of Ambulance Service
Airway Management in Pre-Hospital Care

Deakin C et all.

http://jrcalc.org.uk/airway17.6.8.pdf

08/09/2011

Plus on fait, mieux on réussit !

Paramedic training for proficient prehospital intubation. Warner KJ et all. PrehospitalL Emergency Care 2010;14:103–108

 20 intubations avant d'être fiable 

Intubation apprentiisage.JPG

 

06/05/2011

Mieux maîtriser les voies aériennes: Un axe majeur pour réduire la motalité préhospitalière du traumatisé

 

Analysis of Preventable Trauma Deaths and Opportunities for Trauma Care Improvement in Utah

Sanddall T. et all.

JTrauma. 2011;70:970–977

 

Conclusions: The preventable death rate from trauma demonstrated in Utah is similar to that found in other settings where the trauma system is under development but has not reached full maturity. OFIs predominantly exist in the ED and relate to airway management, fluid resuscitation, and chest injury management. Resource organization and education of ED primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in this mixed urban and rural setting. Similar opportunities exist in the prehospital and post-ED phases of care.

 

PrevDeath.JPG

15/02/2011

Intubation préhospitalière: Que penser de l'AIRTRAQ ?

Comme pour tout il faut s'entraîner et on n'inove pas. On rappelle que, en conditions de combat,  le contrôle des voies aériennes a pour but essentiellemment de prévenir l'obstruction des voies aériennes, de prévenir l'inhalation du contenu gastrique. Le traitement d'une détresse respiratoire fait appel avant tout à l'oxygénothérapie si vous disposez d'oxygène, au traitement d'une cause spécifique (pneumo ou hémothorax, volet thoracique, plaie soufflante), à l'assistance ventilatoire au ballon par masque facial et EVENTUELLEMENT après intubation ou coniotomie sur une canule de 6 mm si les conditions tactiques le permettent.

 

Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: A randomized control trial
Trimmel H et all.

Crit Care Med 2011 Vol. 39, No. 3, 1-5

Objectives: The optical Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) has been shown to have advantages when compared with direct laryngoscopy in difficult airway patients. Furthermore, it has been suggested that it is easy to use and handle even for inexperienced advanced life support providers. As such, we sought to assess whether the Airtraq may be a reliable alternative to conventional intubation when used in the prehospital setting.

Design, Setting, and Patients: Prospective, randomized control trial in emergency patients requiring endotracheal intubation provided by anesthesiologists or emergency physicians responding with an emergency medical service helicopter or ground unit associated with the Department of Anesthesiology, General Hospital, Wiener Neustadt, Austria.

Measurements and Main Results: During the 18-month study period, 212 patients were enrolled. When the Airtraq was used as first-line airway device (n = 106) vs. direct laryngoscopy (n =106), success rate was 47% vs. 99%, respectively (p < .001). Reasons for failed Airtraq intubation were related to the fiberoptic characteristic of this device (i.e., impaired sight due to blood and vomitus, n = 11) or to assumed handling problems (i.e., cuff damage, tube misplacement, or inappropriate visualization of the glottis, n = 24). In 54 of 56 patients where Airtraq intubation failed, direct laryngoscopy was successful on the first attempt; in the remaining two and in one additional case of failed direct laryngoscopy, the airway was finally secured employing the Fastrach laryngeal mask. There was no correlation between success rates and body mass index, age, indication for airway management, emergency medical service unit, or experience of the physicians.

intubation,voies aériennes



Conclusions: Based on these results, the use of the Airtraq laryngoscope as a primary airway device cannot be recommended in the prehospital setting without significant clinical experience obtained in the operation room. We conclude that the clinical learning process of the Airtraq laryngoscope is much longer than reported in the anesthesia literature. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

| Tags : intubation, airway

05/02/2011

Etude NEMESIS: Out-of-hospital airway management in the United States

Un travail prospectif recensant toutes les manoeuvres de contrôle des voies aériennes aux USA vient d'être publié ( Out-of-hospital airway management in the United States - Wang HE et all. -doi:10.1016/j.resuscitation.2010.12.014). Ce document est intéressant car il confirme que l'intubation est le mode premier de contrôle de la ventilation aux USA suivi par la ventilation manuelle au ballon. Le recours à des disposiifs laryngés ne vient qu'au 4ème rang après la mise en oeuvre de technqiues de ventilation non invasive. L'apprentissage de l'intubation reste donc un objectif essentiel. Les tableaux suivant en présentent les principaux résultats.

 

0b.jpeg

 

Table 1. Prevalence of airway management interventions. Table includes only EMS agencies reporting at least one procedure in the NEMSIS 2008 data set. Percentages reflect portion of 2,333,254 total patient care events. Prevalence estimates not calculated for King LT and foreign body removal due to the small numbers of events. BiPAP = bilevel positive airway pressure. CPAP = continuous positive airway pressure. PEEP = positive end expiratory pressure.

Intervention
N
(N per 100,000  care events; 95%CI)
Bag-valve-mask ventilation 8809 (378; 370–386)
Other ventilation (bag-valve, mechanical, unspecified) 12,241 (525; 516–534)
Endotracheal intubation 10,356 (444; 436–453)
 Orotracheal intubation 9130 (392; 384–400)
 Nasotracheal intuabtion 1064 (46; 43–48)
 Rapid sequence intubation 371 (16; 14–18)
Alternate airway 2246 (96; 92–100)
 Combitube 1521 (65; 62–69)
 Esophageal-Obturator Airway (EOA) 175 (8; 6–9)
 Laryngeal Mask Airway 571 (24; 23–27)
 King LT 4 (Not calculated)
Cricothyroidotomy 88 (4; 3–5)
BiPAP/CPAP 4456 (191; 186–197)
Oropharyngeal airway 4623 (198; 193–204)
Nasopharyngeal airway 37,298 (160; 158–161)
Colorimetric tube confirmation 7007 (300; 294–308)
Bulb tube confirmation 646 (28; 26–30)
Nebulizer 12,796 (549; 539–558)
PEEP 2614 (112; 108–117)
Suction 8115 (348; 341–356)
Foreign body removal 1 (Not calculated)

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Table 3. Airway intervention success. Includes only orotracheal, nasotracheal and rapid sequence intubation and alternate airway insertions where procedural success was reported. ETI success was reported for only 8418 of 10,356 ETI.

Procedure
Successful

(% Successful)

Odds ratio (95% CI)
Endotracheal intubation 6482/8418 (77.0; 76.1–77.9) Referent
 Cardiac arrests  3494/4482 (78.0; 76.7–79.2) 0.8 (0.6–0.9)
 Non-arrest medical  616/846 (72.8; 69.7–75.8) 1.3 (1.1–1.7)
 Non-arrest injury  417/505 (82.6; 79.0–85.8) Referent
 Pediatric age < 10 years 295/397 (74.3; 69.7–78.5) 1.3 (0.9–1.9)
 Pediatric age 10–19 years 228/289 (78.9; 73.7–83.5) 1.2 (0.9–1.5)
 Adult age > 19 years 5829/7552 (77.2; 76.2–78.1) N/A
Rapid-sequence intubation 289/355 (81.4; 77.0–85.3)  
Population setting      
 Rural 945/1228 (77.0; 74.6–79.3) Referent
 Suburban 1094/1490 (73.4; 71.2–75.7) 0.8 (0.7–0.99)
 Urban 4153/5301 (78.3; 77.2–79.5) 1.1 (0.9–1.3)
 Wilderness 278/383 (72.6; 68.1–77.1) 0.8 (0.6–1.03)
US census region      
 Midwest 1604/1920 (83.5; 81.9–85.2) 2.1 (1.8–2.4)
 Northeast 779/917 (85.0; 82.6–87.3) 2.3 (1.9–2.8)
 South 2801/3952 (70.9; 69.5–72.3) Referent
 West 1298/1629 (79.7; 77.7–81.6) 1.6 (1.4–1.9)
Alternate airways 1564/1794 (87.2; 85.5–88.7)
 Combitube 971/1162 (83.6; 81.3–85.6) Referent
 Esophageal Obturator Airway 88/104 (84.6; 76.2–90.9) 1.1 (0.6–2.0)
 Laryngeal Mask Airway 505/530 (95.3; 93.1–96.9) 4.0 (2.6–6.4)
 King 4/4 (100.0; 40.0–100.0) N/A
 Cricothyroidotomy (needle and open) 61/70 (87.1; 77.0–93.9) N/A

ETI = endotracheal intubation. US = United States.

a Subgroups do not add up to total because of unknown cardiac arrest status for 5244 cases. Univariable odds ratios presented for selected comparisons only.

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Abstract

-----Among 4,383,768 EMS activations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1–77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children <10 years 295/397 (74.3%), children 10–19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapid-sequence intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000).

Conclusions

In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management.

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| Tags : airway, intubation

31/12/2010

Intubation préhospitalière: Histoire de lame

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 -  
doi:10.1016/j.annemergmed.2010.10.011

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:

  1. 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)

    Jabre 1.JPG

    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.

     

     

    Jabre 2.JPG

    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.

     

     

    Jabre 3.JPG


     

     

 

| Tags : intubation, airway