scholarly journals Drug-free tracheal intubation by specialist paramedics (critical care) in a United Kingdom ambulance service: a service evaluation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Silas Houghton Budd ◽  
Eleanor Alexander-Elborough ◽  
Richard Brandon ◽  
Chris Fudge ◽  
Scott Hardy ◽  
...  
Keyword(s):  
Critical Care ◽  
Tracheal Intubation ◽  
Success Rate ◽  
Service Evaluation ◽  
Ambulance Service ◽  
Lehane Grade ◽  
First Pass ◽  
The Subject ◽  
Drug Free ◽  
Hospital Cardiac Arrest

Abstract Background Drug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it. Methods We conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie. Results There were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%). Bougie use was documented in 83.4% on the first attempt, 93.5% on the second attempt and 100% on the third attempt, Conclusion Specialist paramedics (critical care) are able to deliver drug-free tracheal intubation with good first-pass success and high overall success and are therefore both safe and competent at this intervention.

scholarly journals Tracheal Intubation by Specialist Paramedics (Critical Care) in a United Kingdom Ambulance Service: a Service Evaluation.

2021 ◽  
Author(s):  
Silas Houghton Budd ◽  
Eleanor Alexander-Elborough ◽  
Richard Brandon ◽  
Chris Fudge ◽  
Scott Hardy ◽  
...  
Keyword(s):  
Critical Care ◽  
Tracheal Intubation ◽  
Success Rate ◽  
Service Evaluation ◽  
Ambulance Service ◽  
Lehane Grade ◽  
First Pass ◽  
The Subject ◽  
Drug Free ◽  
Hospital Cardiac Arrest

Abstract BackgroundDrug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it.MethodsWe conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie.ResultsThere were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%).ConclusionSpecialist paramedics (critical care) are able to deliver drug-free tracheal intubation with high first-pass success and very high overall success and are therefore both safe and competent at this intervention.

Macintosh laryngoscope, i-view™, and C-MAC® video laryngoscopes for tracheal intubation with an aerosol box: A randomized, crossover, manikin study

2020 ◽  
Author(s):  
Toshiyuki Nakanishi ◽  
Yoshiki Sento ◽  
Yuji Kamimura ◽  
Kazuya Sobue
Keyword(s):  
Intensive Care ◽  
Tracheal Intubation ◽  
Success Rate ◽  
Macintosh Laryngoscope ◽  
Video Laryngoscope ◽  
Interquartile Range ◽  
Intubation Time ◽  
Lehane Grade ◽  
Significant Difference ◽  
Difficulty Scale

Abstract Background: The aerosol box was designed to prevent cough droplets from spreading, but it can impede tracheal intubation. We tested the hypothesis that the C-MAC® video laryngoscope (C-MAC) with an external display is more useful than the i-view™ video laryngoscope (i-view) with an integrated display, or a Macintosh direct laryngoscope (Macintosh) for tracheal intubation with an aerosol box.Methods: This prospective, randomized, crossover simulation study was conducted at an operating room of the two hospitals (a university hospital and a tertiary teaching hospital). We recruited 37 medical personnel (36 anesthesiologists and 1 dental anesthesiologist) who were working in the fields of anesthesia and intensive care with > 2 years of dedicated anesthesia experience from five hospitals. We divided the participants into six groups to use the laryngoscope in a determined order. After the training using each laryngoscope without a box, the participants performed tracheal intubation thrice with each laryngoscope with at least two-hour intervals. The primary outcome was the intubation time. The secondary outcomes were the success rate, Cormack-Lehane grade, and subjective difficulty scale score (numeric rating scale 0–10, 0: no difficulty, 10: highest difficulty). We used the Friedman test and the Wilcoxon signed-rank test with Bonferroni adjustment. Data are shown as median [interquartile range].Results: Thirty-seven personnel (11 women and 26 men) with 12 [5–19] (median [interquartile range]) years of anesthesia and intensive care experience were enrolled. There was no significant difference in the intubation time: 30 [26–32] s for Macintosh, 29 [26–32] s for i-view, and 29 [25–31] s for C-MAC (P=0.247). The success rate was 95%–100% without significant difference (P=0.135). The i-view and C-MAC video laryngoscopes exhibited superior Cormack-Lehane grades and lower subjective difficulty scale scores than the Macintosh laryngoscope; however, there were no differences between the i-view and C-MAC video laryngoscopes.Conclusions: Rapid and highly successful tracheal intubation was possible with Macintosh laryngoscope, i-view, and C-MAC video laryngoscopes on a manikin with an aerosol box. Improved Cormack-Lehane grade and ease of procedure may support the use of video laryngoscopes.Trial registration: UMIN Clinical Trials Registry, identifier UMIN000040269.

Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit

2018 ◽  
Vol 129 (2) ◽  
pp. 321-328 ◽  
Author(s):  
Manuel Taboada ◽  
Patricia Doldan ◽  
Andrea Calvo ◽  
Xavier Almeida ◽  
Esteban Ferreiroa ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Tracheal Intubation ◽  
Success Rate ◽  
Operating Room ◽  
Direct Laryngoscopy ◽  
Technical Difficulty ◽  
Time Frame ◽  
Lehane Grade ◽  
First Time

Abstract What We Already Know about This Topic What This Article Tells Us That Is New Background Tracheal intubation is a common intervention in the operating room and in the intensive care unit. The authors hypothesized that tracheal intubation using direct laryngoscopy would be associated with worse intubation conditions and more complications in the intensive care unit compared with the operating room. Methods The authors prospectively evaluated during 33 months patients who were tracheally intubated with direct laryngoscopy in the operating room, and subsequently in the intensive care unit (within a 1-month time frame). The primary outcome was to compare the difference in glottic visualization using the modified Cormack-Lehane grade between intubations performed on the same patient in an intensive care unit and previously in an operating room. Secondary outcomes were to compare first-time success rate, technical difficulty (number of attempts, operator-reported difficulty, need for adjuncts), and the incidence of complications. Results A total of 208 patients met inclusion criteria. Tracheal intubations in the intensive care unit were associated with worse glottic visualization (Cormack-Lehane grade I/IIa/IIb/III/IV: 116/24/47/19/2) compared with the operating room (Cormack-Lehane grade I/IIa/IIb/III/IV: 159/21/16/12/0; P < 0.001). First-time intubation success rate was lower in the intensive care unit (185/208; 89%) compared with the operating room (201/208; 97%; P = 0.002). Tracheal intubations in the intensive care unit had an increased incidence of moderate and difficult intubation (33/208 [16%] vs. 18/208 [9%]; P < 0.001), and need for adjuncts to direct laryngoscopy (40/208 [19%] vs. 21/208 [10%]; P = 0.002), compared with the operating room. Complications were more common during tracheal intubations in the intensive care unit (76/208; 37%) compared with the operating room (13/208; 6%; P < 0.001). Conclusions Compared with the operating room, tracheal intubations in the intensive care unit were associated with worse intubation conditions and an increase of complications.

Abstract 202: Video Laryngoscopy for Out of Hospital Cardiac Arrest

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Ryan M Huebinger ◽  
Hutch Stilgenbauer ◽  
Jeffrey L Jarvis ◽  
Daniel Ostermayer ◽  
Kevin Schulz ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Success Rate ◽  
Mixed Model ◽  
Model Analysis ◽  
Video Laryngoscopy ◽  
Mixed Model Analysis ◽  
Shockable Rhythm ◽  
First Pass ◽  
Bystander Cpr ◽  
Hospital Cardiac Arrest

Introduction: Intubation is an essential component of cardiac arrest resuscitation. While prior studies have evaluated video laryngoscopy (VL) to assist intubation for in hospital cardiac arrest, there is a paucity of research evaluating VL for out of hospital cardiac arrest (OHCA). We sought to evaluate the association of video laryngoscopy with first pass success and ROSC. Hypothesis: Video laryngoscopy improves first pass success rate and improves the rate of ROSC Methods: We analyzed the 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record used by 1289 EMS agencies in the US. We included all adult (age >18 years), non-traumatic cardiac arrests that were intubated with an endotracheal device. We applied a chi2 test to evaluate the first pass success rate for VL vs direct laryngoscopy (DL). We then created a mixed model, fitting agency as a random intercept and adjusting for age, gender, race, location of arrest, witnessed arrest, initial shockable rhythm, and bystander CPR. We applied the mixed model to analyze the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC for greater than 20 minutes). Results: We included 22,097 patients cared for by 914 agencies. 5,674 (25.7%) patients were intubated with video laryngoscopy. The median age was 66 (IQR 55-77). 61.9% of patients were male and 73.0% were white. 71.9% of cardiac arrest happened at home, 56.8% of were witnessed, 37.4% had bystander CPR, and 20.6% had a shockable rhythm. Compared to DL, VL had a lower rate of bystander CPR (41.4% v 36.1%, p<.001), but other characteristics were similar between the groups. We found that VL had a higher first pass success rate than DL (75.1% v 69.5%, p<.001). Using a mixed model analysis, VL was associated with a higher rate of first pass success (OR 1.5, CI 1.3-1.6), but VL was not associated with improvement in ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2). Conclusion: VL had a higher first pass success rate than DL, and on adjusted, mixed-model analysis, VL use was associated with increased rate of first pass success. However, VL was not associated with increased rate of ROSC

scholarly journals Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model

BMJ Open ◽  
2019 ◽  
Vol 9 (7) ◽  
pp. e028574
Author(s):  
Johannes von Vopelius-Feldt ◽  
Jane Powell ◽  
Jonathan Richard Benger
Keyword(s):  
Cardiac Arrest ◽  
Critical Care ◽  
Cost Effectiveness ◽  
Life Support ◽  
Advanced Life Support ◽  
Cost Effective ◽  
Ambulance Service ◽  
Sensitivity Analyses ◽  
Decision Analysis Model ◽  
Hospital Cardiac Arrest

ObjectivesThis research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective?SettingA single National Health Service ambulance service and a charity-funded prehospital critical care service in England.ParticipantsThe patient population is adult, non-traumatic OHCA.MethodsWe combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses.ResultsCosts of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%–5%.ConclusionThis is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field.Trial registration numberISRCTN18375201

Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit?

2021 ◽  
Author(s):  
Chetna K. Pande ◽  
Kelsey Stayer ◽  
Thomas Rappold ◽  
Madeleine Alvin ◽  
Keri Koszela ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Success Rate ◽  
Endotracheal Intubation ◽  
Pediatric Intensive Care ◽  
Training Level ◽  
Provider Training ◽  
Factors Associated ◽  
First Pass

AbstractEndotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.

scholarly journals A service evaluation of transport destination and outcome of patients with post-ROSC STEMI in an English ambulance service

2020 ◽  
Vol 5 (1) ◽  
pp. 32-36
Author(s):  
Anthony Platt
Keyword(s):  
Survival Rates ◽  
Coronary Intervention ◽  
Service Evaluation ◽  
Spontaneous Circulation ◽  
Ambulance Service ◽  
Inclusion Criteria ◽  
Percutaneous Coronary ◽  
St Elevation ◽  
The Uk ◽  
Hospital Cardiac Arrest

Background: In the UK, there are approximately 60,000 cases of out-of-hospital cardiac arrest (OHCA) each year. There is mounting evidence that post-resuscitation care should include early angiography and primary percutaneous coronary intervention (pPCI) in cases of OHCA where a cardiac cause is suspected. Yorkshire Ambulance Service (YAS) staff can transport patients with a return of spontaneous circulation (ROSC) directly to a pPCI unit if their post-ROSC ECG shows evidence of ST elevation myocardial infarction (STEMI). This service evaluation aimed to determine the factors that affect the transport destination, hospital characteristics and 30-day survival rates of post-ROSC patients with presumed cardiac aetiology.Methods: All patient care records (PCRs) previously identified for the AIRWAYS-2 trial between January and July 2017 were reviewed. Patients were eligible for inclusion if they were an adult non-traumatic OHCA, achieved ROSC on scene and were treated and transported by (YAS). Descriptive statistics were used to analyse the data.Results: 478 patients met the inclusion criteria. 361/478 (75.6%) patients had a post-ROSC ECG recorded, with 149/361 (41.3%) documented cases of STEMI and 88/149 (59.1%) referred to a pPCI unit by the attending clinicians. 40/88 (45.5%) of referrals made were accepted by the pPCI units. Patients taken directly to pPCI were most likely to survive to 30 days (25/39, 53.8%), compared to patients taken to an emergency department (ED) at a pPCI-capable hospital (34/126, 27.0%), or an ED at a non-pPCI-capable hospital (50/310, 16.1%).Conclusion: Staff should be encouraged to record a 12-lead ECG on all post-ROSC patients, and make a referral to the regional pPCI-capable centre if there is evidence of a STEMI, or a cardiac cause is likely, since 30-day survival is highest for patients who are taken directly for pPCI. Ambulance services should continue to work with regional pPCI-capable centres to ensure that suitable patients are accepted to maximise potential for survival.

scholarly journals The Cardiac Arrest Support Tier: a service evaluation

2020 ◽  
Vol 5 (2) ◽  
pp. 38-47
Author(s):  
Matthew Metcalf ◽  
Matthew Robinson ◽  
Pippa Hall ◽  
James Goss
Keyword(s):  
Cardiac Arrest ◽  
Chest Compression ◽  
Service Evaluation ◽  
Spontaneous Circulation ◽  
Ambulance Service ◽  
Online Questionnaire ◽  
Hazardous Area ◽  
Response Team ◽  
Full Complement ◽  
Hospital Cardiac Arrest

Aim: This service evaluation seeks to determine whether the pre-hospital Cardiac Arrest Support Tier (CAST), implemented by a Hazardous Area Response Team (HART), was clinically effective, feasible and acceptable during its pilot year.Methods: Chest compression feedback, provision of Return of Spontaneous Circulation (ROSC) care and CAST paramedic exposure to Out-of-Hospital Cardiac Arrest (OHCA) were audited. The number of incidents that CAST responded to and the number of staff it committed were also assessed. An online questionnaire was used to gauge acceptability of the project among frontline Ambulance Service Trust staff.Results: CAST attended 178 OHCAs and committed a median of three (IQR 2‐3) paramedics to each incident. In comparison to data from both South Western Ambulance Service Foundation Trust (SWASFT) and the National Ambulance Service in England, CAST delivered the full complement of post-ROSC care more frequently during the same period (CAST = 80% vs SWASFT = 68.5% vs England = 77.46%). CAST paramedics had a median exposure to 15.5 (IQR 12‐19) OHCAs during the pilot year. Unfortunately, chest compression feedback was unavailable due to ongoing equipment inaccuracies and failure.Additionally 64.6% (n = 42/65) of SWASFT respondents believed CAST to be beneficial to resuscitation attempts, 63.1% (n = 41/65) would like CAST to continue to support resuscitation attempts in the future and 55.6% (n = 35/63) felt supported by CAST staff on scene.Conclusion: CAST is logistically feasible, is acceptable to the majority of SWASFT staff and demonstrated the successful delivery of evidence-based practice (EBP) to OHCA incidents.

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