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Analysis of intubations: before and after establishment of a rapid sequence intubation protocol
Scientific Session, October 17 ANALYSIS OF INTUBATIONS: BEFORE AND AFTER ESTABLISHMENT OF A RAPID SEQUENCE INTUBATION PROTOCOL Lisa Anderson,* William Rose,** Steven Edmond,* HealthNet Aeromedical Service* and the Dept. of Emergency Medicine,** West Virginia University Hospital, Morgantown, WV 26506 Introduction: After discovery that the success rate for intubations by our flight team was <75%, a rapid sequence intubation (RSI) protocol for flight nurse and paramedic use in the field was established. This RSI protocol allows increased doses of sedative agents and adjunctive use of neuromuscular blocking agents to facilitate intubations. Through our QI process of reviewing all intubations, subsequent success rates seemed to have improved markedly. The objective of this study was to analyze intubation success rates before and after establishment of the RSI policy. Methods: Retrospective review was performed of 2,928 flights over a 5 year period, yielding 200 consecutive intubations (100 before and 100 after RSI). Data regarding nature of injury or illness, Glasgow Coma Scale (GCS), success of procedure, complications encountered, and demographic information were collected. Results: Of flights occurring before the RSI protocol, 100 intubations were attempted out of 1,635 flights (6.1%) with a suc~ss rate of 73%. Of the flights occurring after the RSI protocol, 100 intubations were attempted out of 1,293 flights (7.7%), with a success rate of 96%. The higher success rate in the RSI group (96% vs. 73%) was statistically significant (Z2= 20.2, p<0.01), while no significant difference was found between the two groups with regard to age, sex, GCS, nature of injury, or percent intubated. Of the 200 intubated patients, average age was 34.7 years; 133/200 (67%) were male; 35/200 (17.5%) were arrested; 150/200 (75%) were trauma related, and of these, the average GCS = 6. Of the RSI group, 30/100 (30%) were actually intubated using paralytic agents. Few problems were encountered using this RSI protocol. Conclusion: Use of sedative and neuromuscular blocking agents as adjuncts to supplement intubations by aeromedical personnel has markedly enhanced our success rate of this procedure, with minimal additional risk.
Air Medical Journal
13:10 October 1994
A N A N A L Y S I S OF P R E H O S P I T A L P E D I A T R I C A N D ADULT INTUBATION
Carl R. Boyd, W i l l i a m B o s w e l l , Nema McElveen, M i c h a e l Sharp, E l a i n e Frantz LIFESTAR, M e m o r i a l M e d i c a l Center, Savannah, G e o r g i a INTRODUCTION: Pediatric airway control i n c l u d i n g e n d o t r a c h e a l i n t u b a t i o n (ETT) can be a considerable clinical challenge, particularly in the prehospital setting. Most protocols r e c o m m e n d ETT intubation for serious head injury as i n d i c a t e d by a GCS $8. The purpose of this study was to e v a l u a t e the f r e q u e n c y of E T T i n t u b a t i o n in adult and p e d i a t r i c p a t i e n t s w i t h a GCS of $8 in the field, who are subsequently transported by h o s p i t a l based h e l i c o p t e r EMS (HHEMS). METHODS: A retrospective, descriptive study of p e d i a t r i c (~14 years) and adult p a t i e n t s t r a n s p o r t e d by HHEMS w i t h a GCS $8 d u r i n g the time p e r i o d of J a n u a r y 1988 t h r o u g h M a r c h 1994 was undertaken. Differences
between
the
groups
were
e v t l u a t e d u s i n g CHI square a n a l y s i s and an alpha level of 0.05 was u s e d for significance. RESULTS: In the study group, 63(15%) pediatric patients (PEDS) and 353(85%) adult patients met the inclusion criteria. 38(60%) of PEDS w e r e ETT intubated. PEDS s t u d i e d had a m e a n age of 7, m e a n p e d i a t r i c GCS of 5, m e a n p e d i a t r i c TS of 5, and a m e a n ISS of 28. 267(76%) adults w e r e ETT intubated. Of the adult group, the m e a n age w a s 35, m e a n GCS 6, m e a n TS 9, and the m e a n ISS 33. The 16% d i f f e r e n c e in the f r e q u e n c y of ETT intubation was found to be s i g n i f i c a n t (P~.01). Of the 25 non-intubated PEDS, unsuccessful attempts were made on 20(80%). 9 PEDS(36%) w e r e s u b s e q u e n t l y intubated immediately upon arrival to the Trauma Center. 14 PEDS (58%) in the n o n - i n t u b a t e d group had s i g n i f i c a n t head / n e c k i n j u r i e s e v i d e n c e d by CT scan. Of the 74 non-intubated adults, u n s u c c e s s f u l a t t e m p t s w e r e m a d e on 29 (39%). Six(8%) of the p a t i e n t s were subsequently i n t u b a t e d upon arrival to the Trauma Center. 61(82%) had s i g n i f i c a n t h e a d / n e c k injuries d i a g n o s e d by CT. CONCLUSION: Pediatric patients in coma were not intubated with the same f r e q u e n c y as adults. The d i f f i c u l t y of p e d i a t r i c airway c o n t r o l m a y r e q u i r e an increased level of training and experience in order to follow ATLS guidelines for airway management in children.
409
Air Medical Journal
13:10 October 1994
A N A N A L Y S I S OF P R E H O S P I T A L P E D I A T R I C A N D ADULT INTUBATION
Carl R. Boyd, W i l l i a m B o s w e l l , Nema McElveen, M i c h a e l Sharp, E l a i n e Frantz LIFESTAR, M e m o r i a l M e d i c a l Center, Savannah, G e o r g i a INTRODUCTION: Pediatric airway control i n c l u d i n g e n d o t r a c h e a l i n t u b a t i o n (ETT) can be a considerable clinical challenge, particularly in the prehospital setting. Most protocols r e c o m m e n d ETT intubation for serious head injury as i n d i c a t e d by a GCS $8. The purpose of this study was to e v a l u a t e the f r e q u e n c y of E T T i n t u b a t i o n in adult and p e d i a t r i c p a t i e n t s w i t h a GCS of $8 in the field, who are subsequently transported by h o s p i t a l based h e l i c o p t e r EMS (HHEMS). METHODS: A retrospective, descriptive study of p e d i a t r i c (~14 years) and adult p a t i e n t s t r a n s p o r t e d by HHEMS w i t h a GCS $8 d u r i n g the time p e r i o d of J a n u a r y 1988 t h r o u g h M a r c h 1994 was undertaken. Differences
between
the
groups
were
e v t l u a t e d u s i n g CHI square a n a l y s i s and an alpha level of 0.05 was u s e d for significance. RESULTS: In the study group, 63(15%) pediatric patients (PEDS) and 353(85%) adult patients met the inclusion criteria. 38(60%) of PEDS w e r e ETT intubated. PEDS s t u d i e d had a m e a n age of 7, m e a n p e d i a t r i c GCS of 5, m e a n p e d i a t r i c TS of 5, and a m e a n ISS of 28. 267(76%) adults w e r e ETT intubated. Of the adult group, the m e a n age w a s 35, m e a n GCS 6, m e a n TS 9, and the m e a n ISS 33. The 16% d i f f e r e n c e in the f r e q u e n c y of ETT intubation was found to be s i g n i f i c a n t (P~.01). Of the 25 non-intubated PEDS, unsuccessful attempts were made on 20(80%). 9 PEDS(36%) w e r e s u b s e q u e n t l y intubated immediately upon arrival to the Trauma Center. 14 PEDS (58%) in the n o n - i n t u b a t e d group had s i g n i f i c a n t head / n e c k i n j u r i e s e v i d e n c e d by CT scan. Of the 74 non-intubated adults, u n s u c c e s s f u l a t t e m p t s w e r e m a d e on 29 (39%). Six(8%) of the p a t i e n t s were subsequently i n t u b a t e d upon arrival to the Trauma Center. 61(82%) had s i g n i f i c a n t h e a d / n e c k injuries d i a g n o s e d by CT. CONCLUSION: Pediatric patients in coma were not intubated with the same f r e q u e n c y as adults. The d i f f i c u l t y of p e d i a t r i c airway c o n t r o l m a y r e q u i r e an increased level of training and experience in order to follow ATLS guidelines for airway management in children.
409