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Upper airway obstruction in handicapped persons
Abstracts / Resuscitation 81S (2010) S1–S114 AP090 Upper airway obstruction in handicapped persons Nielepiec - Jalosinska A. Clinical Department of Emergency Medicine, The Medical Centre of Postgraduate Education, Warsaw, Poland Purpose of the study: Foreign body aspiration is most common cause of upper airway obstruction in handicapped persons with neurologic disorders. Families who take care of these persons have to perform sequence of airway obstruction. This maneuver is most important and difficult in persons with high body mass, sitting on the wheelchair. Purpose of this study is modification of airway obstruction sequence dedicated to this people. The problem is how to give them abdominal thrusts. Materials and methods: 22 years old choking female on the wheelchair. Her body mass was 60 kg and it wasn’t possible to pick her up. She was at home with her mother—emergency physician. Mother performed airway obstruction sequence on the wheelchair. Slope her forward and gave her 5 effective back blocks. There was no improvement. Woman stood behind, wrapped hands around wheelchair and waist to give her abdominal thrusts. The second was successful. Results: In our opinion this technique modification is very simple. Specially relate to persons who are not independent and their body mass is high. The Heimlich maneuver is the most commonly used intervention, with high rate of patient improvement. Conclusions:
S57
Methods: In this prospective study, we examine our initial 41 cases of out-of-hospital cardiac arrest where capnography was used as a tool for cardiopulmonary status, since January 2010. The patients were intubated and measurements of EtCO2 were collected for each patient during CPR. We theorized that values less than 10 mmHg after 20 min of advanced life support (ALS) would predict unsuccessful ROSC. Results: An obvious medical cause was found in 92.7% of the occurrences and 65.9% were male patients, with an average age of 60 years old. 10 patients (24.4%) were successfully resuscitated and transported to the hospital with ROSC. EtCO2 after 20 min of ALS averaged 10 ± 2 mmHg in patients who did not have ROSC and 31 ± 2 mmHg in those who did. When asked if capnography facilitated the decision to stop CPR, 68.3% of the medical staff gave a positive answer. Conclusion: In our study, end-tidal carbon dioxide levels of more than 17 ± 3 mmHg after 20 min may be used to predict ROSC with some accuracy. EtCO2 levels should always be monitored during CPR and considered a useful, noninvasive, predictor of (un)successful resuscitation from cardiac arrest which could help determine when to cease CPR efforts. This study is still ongoing and consequently these results are preliminary. doi:10.1016/j.resuscitation.2010.09.237 AP093 Does the use of supraglottic airway devices compared with bag-valve-mask alone improve any outcome? Propensity-adjusted analysis of Japan Utstein registry Takyu H. 1 , Kaneko H. 2 , Tanaka H. 3 , Hatanaka T. 4 , Nakagawa T. 5 , Takeuchi A. 5 , Mabuchi N. 6 , Nagase A. 7 , Noguchi H. 8
1. Airway obstruction sequence in handicapped persons can be successfully done on the wheelchair. 2. Unfortunately there is no information in ERC guidelines how perform this procedure in disabled people. 3. The Heimlich maneuver is effective also in sitting position. doi:10.1016/j.resuscitation.2010.09.235 AP091 Rapid sequence induction lege artis—A myth? Braunecker S., Wetsch W.A., Hinkelbein J. Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Germany Background: Securing the airway is a core competence in emergency medicine. Nevertheless, airway management presents a major challenge not only for nonanaesthesiologists but also for anaesthesia experienced emergency physicians. While patients in elective surgery are fasted, the emergency patient is always considered not to be soberly and requires a corresponding rapid sequence induction (RSI). In addition to a relevant experience in the implementation of RSI, an optimal preparation of the patient (pre-oxygenation, drug selection, cricoid pressure and correct head and neck position) minimizes complications. Due to the controversy regarding the best position and whether the head-up, head-down, or supine position is the safest during induction of anesthesia in full-stomach patients, we conducted a systematic review and meta-analysis. Methods: We searched the main medical databases (PubMed, Medline), Google Scholar and Google using combinations of applicable terms (“head”, “neck”, “position”, “rapid sequence induction”, “RSI”) for articles published between 01.01.1950 and 30.06.2010. Additionally, references and related articles were also screened. Literature was analyzed by two independent anesthesiologists for different head and neck positions in RSI. Results: Altogether n = 16 papers were identified concerning the position during RSI. Here, no RCT was found. After closer consideration, only one paper showed the lack of aspiration in head-up position without comparison to other positions. Conclusion: There is no scientific proof whether the head-up, head-down, or supine position is the safest during RSI. Until today, there is no verification about the safest position of the head and neck during induction of anesthesia in non-soberly patients. Further trials are needed to discover the safest position for RSI. For this reason a survey of the position in RSI associated with adverse events like regurgitation and aspiration seems to be required.
1 Department
of Rehabilitation, Chubu Gakuin University, Seki, Japan Nagoya City Fire Department, Nagoya, Japan Kokushikan University, Graduate school of EMS, Tama, Japan 4 Emergency Life-Saving Technique Academy, Kitakyusyu, Japan 5 Advanced Critical Care Center, Aichi Medical University, Nagakute, Japan 6 Department of Anesthesiology and Intensive Care Medicine, Gifu Prefectural Tajimi Hospital, Tajimi, Japan 7 Nagoya Ekisaikai Hospital, Nagoya, Japan 8 Department of Emergency and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan 2 3
Background: Supraglottic airway devices (SGA) are often used for out-of-hospital cardiac arrest (OHCA) patients. However it remains unclear whether a use of SGA improves survival outcomes of OHCA compared with bag-valve-mask (BVM) alone.1,2 Material and method: Data of OHCA patients from January 1, 2007 through December 31, 2008 were extracted from the nationwide Utstein-style registry of Japan. We excluded patients younger than 18 and older than 75 of age. Also excluded are cardiac arrest witnessed by EMS personnel, trauma- or malignancy-related cardiac arrest and patients for whom resuscitation was not attempted. The primary outcome measure was 1-month survival with minimal neurologic impairment (CPC 1 or 2) and secondary outcome was return of spontaneous circulation (ROSC) before arriving at hospital. One to one matching based on a propensity score and conditional logistic regression modeling technique were used to calculate the relative risk (RR) of SGA over BVM, adjusting for potential confounders including witness status of the arrest, bystander cardiopulmonary resuscitation, AED use, initial ECG rhythm, and call-response interval. Results: Out of a total of 21,582 eligible patients, the propensity score matching yielded 6816 matched pairs.. A RR (95%CI) of SGA for the CPC score at 1-month post-arrest was 0.38 (0.31–0.47) and a RR (95%CI) of SGA for the ROSC was 0.40 (0.34–0.47). There was not significant dose-response relationship between the ambulance call to hospital arrival at hospital interval and those two Relative Risks. Conclusion: Our large-scale database analysis has revealed that a use of SGA is negatively associated with both the immediate outcome and neurological outcome. The results appear to warrant prospective, interventional trial concerning the effectiveness of the use of SGA over BVM. References 1. Morimura N. Comparison of arterial blood gases of laryngeal mask airway and bagvalve-mask ventilation in out-of-hospital cardiac arrests. Circ J 2009;73:490–562. 2. Rumball CJ, MacDonald D. The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest. Prehos Emerg Care 1997;1:1–10.
doi:10.1016/j.resuscitation.2010.09.236 doi:10.1016/j.resuscitation.2010.09.238 AP092 Capnography as a survival predictor in cardiopulmonary resuscitation Farinha L.F., Dias R., Pinto N., Lufinha A., Nunes J., Catorze N. Prehospital Emergency Medical Team (VMER), Hospital S. Francisco Xavier, Lisbon, Portugal Introduction: Capnography has become a vital part of monitoring in the prehospital setting because it provides information about respiratory rate, respiratory patterns and end-tidal carbon dioxide (EtCO2 ) values. Expired carbon dioxide reflects changes in metabolism, circulation, respiration, the airway and the breathing system. Capnography can detect the presence of pulmonary blood flow even in the absence of major pulses and also can rapidly denote changes in cardiac output, indicative of return of spontaneous circulation (ROSC) following cardiac arrest. Can also be used as a feedback to optimize chest compressions during CPR.
S57
Methods: In this prospective study, we examine our initial 41 cases of out-of-hospital cardiac arrest where capnography was used as a tool for cardiopulmonary status, since January 2010. The patients were intubated and measurements of EtCO2 were collected for each patient during CPR. We theorized that values less than 10 mmHg after 20 min of advanced life support (ALS) would predict unsuccessful ROSC. Results: An obvious medical cause was found in 92.7% of the occurrences and 65.9% were male patients, with an average age of 60 years old. 10 patients (24.4%) were successfully resuscitated and transported to the hospital with ROSC. EtCO2 after 20 min of ALS averaged 10 ± 2 mmHg in patients who did not have ROSC and 31 ± 2 mmHg in those who did. When asked if capnography facilitated the decision to stop CPR, 68.3% of the medical staff gave a positive answer. Conclusion: In our study, end-tidal carbon dioxide levels of more than 17 ± 3 mmHg after 20 min may be used to predict ROSC with some accuracy. EtCO2 levels should always be monitored during CPR and considered a useful, noninvasive, predictor of (un)successful resuscitation from cardiac arrest which could help determine when to cease CPR efforts. This study is still ongoing and consequently these results are preliminary. doi:10.1016/j.resuscitation.2010.09.237 AP093 Does the use of supraglottic airway devices compared with bag-valve-mask alone improve any outcome? Propensity-adjusted analysis of Japan Utstein registry Takyu H. 1 , Kaneko H. 2 , Tanaka H. 3 , Hatanaka T. 4 , Nakagawa T. 5 , Takeuchi A. 5 , Mabuchi N. 6 , Nagase A. 7 , Noguchi H. 8
1. Airway obstruction sequence in handicapped persons can be successfully done on the wheelchair. 2. Unfortunately there is no information in ERC guidelines how perform this procedure in disabled people. 3. The Heimlich maneuver is effective also in sitting position. doi:10.1016/j.resuscitation.2010.09.235 AP091 Rapid sequence induction lege artis—A myth? Braunecker S., Wetsch W.A., Hinkelbein J. Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Germany Background: Securing the airway is a core competence in emergency medicine. Nevertheless, airway management presents a major challenge not only for nonanaesthesiologists but also for anaesthesia experienced emergency physicians. While patients in elective surgery are fasted, the emergency patient is always considered not to be soberly and requires a corresponding rapid sequence induction (RSI). In addition to a relevant experience in the implementation of RSI, an optimal preparation of the patient (pre-oxygenation, drug selection, cricoid pressure and correct head and neck position) minimizes complications. Due to the controversy regarding the best position and whether the head-up, head-down, or supine position is the safest during induction of anesthesia in full-stomach patients, we conducted a systematic review and meta-analysis. Methods: We searched the main medical databases (PubMed, Medline), Google Scholar and Google using combinations of applicable terms (“head”, “neck”, “position”, “rapid sequence induction”, “RSI”) for articles published between 01.01.1950 and 30.06.2010. Additionally, references and related articles were also screened. Literature was analyzed by two independent anesthesiologists for different head and neck positions in RSI. Results: Altogether n = 16 papers were identified concerning the position during RSI. Here, no RCT was found. After closer consideration, only one paper showed the lack of aspiration in head-up position without comparison to other positions. Conclusion: There is no scientific proof whether the head-up, head-down, or supine position is the safest during RSI. Until today, there is no verification about the safest position of the head and neck during induction of anesthesia in non-soberly patients. Further trials are needed to discover the safest position for RSI. For this reason a survey of the position in RSI associated with adverse events like regurgitation and aspiration seems to be required.
1 Department
of Rehabilitation, Chubu Gakuin University, Seki, Japan Nagoya City Fire Department, Nagoya, Japan Kokushikan University, Graduate school of EMS, Tama, Japan 4 Emergency Life-Saving Technique Academy, Kitakyusyu, Japan 5 Advanced Critical Care Center, Aichi Medical University, Nagakute, Japan 6 Department of Anesthesiology and Intensive Care Medicine, Gifu Prefectural Tajimi Hospital, Tajimi, Japan 7 Nagoya Ekisaikai Hospital, Nagoya, Japan 8 Department of Emergency and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan 2 3
Background: Supraglottic airway devices (SGA) are often used for out-of-hospital cardiac arrest (OHCA) patients. However it remains unclear whether a use of SGA improves survival outcomes of OHCA compared with bag-valve-mask (BVM) alone.1,2 Material and method: Data of OHCA patients from January 1, 2007 through December 31, 2008 were extracted from the nationwide Utstein-style registry of Japan. We excluded patients younger than 18 and older than 75 of age. Also excluded are cardiac arrest witnessed by EMS personnel, trauma- or malignancy-related cardiac arrest and patients for whom resuscitation was not attempted. The primary outcome measure was 1-month survival with minimal neurologic impairment (CPC 1 or 2) and secondary outcome was return of spontaneous circulation (ROSC) before arriving at hospital. One to one matching based on a propensity score and conditional logistic regression modeling technique were used to calculate the relative risk (RR) of SGA over BVM, adjusting for potential confounders including witness status of the arrest, bystander cardiopulmonary resuscitation, AED use, initial ECG rhythm, and call-response interval. Results: Out of a total of 21,582 eligible patients, the propensity score matching yielded 6816 matched pairs.. A RR (95%CI) of SGA for the CPC score at 1-month post-arrest was 0.38 (0.31–0.47) and a RR (95%CI) of SGA for the ROSC was 0.40 (0.34–0.47). There was not significant dose-response relationship between the ambulance call to hospital arrival at hospital interval and those two Relative Risks. Conclusion: Our large-scale database analysis has revealed that a use of SGA is negatively associated with both the immediate outcome and neurological outcome. The results appear to warrant prospective, interventional trial concerning the effectiveness of the use of SGA over BVM. References 1. Morimura N. Comparison of arterial blood gases of laryngeal mask airway and bagvalve-mask ventilation in out-of-hospital cardiac arrests. Circ J 2009;73:490–562. 2. Rumball CJ, MacDonald D. The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest. Prehos Emerg Care 1997;1:1–10.
doi:10.1016/j.resuscitation.2010.09.236 doi:10.1016/j.resuscitation.2010.09.238 AP092 Capnography as a survival predictor in cardiopulmonary resuscitation Farinha L.F., Dias R., Pinto N., Lufinha A., Nunes J., Catorze N. Prehospital Emergency Medical Team (VMER), Hospital S. Francisco Xavier, Lisbon, Portugal Introduction: Capnography has become a vital part of monitoring in the prehospital setting because it provides information about respiratory rate, respiratory patterns and end-tidal carbon dioxide (EtCO2 ) values. Expired carbon dioxide reflects changes in metabolism, circulation, respiration, the airway and the breathing system. Capnography can detect the presence of pulmonary blood flow even in the absence of major pulses and also can rapidly denote changes in cardiac output, indicative of return of spontaneous circulation (ROSC) following cardiac arrest. Can also be used as a feedback to optimize chest compressions during CPR.