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Scene endotracheal intubation performed by trained physicians is safe and efficient
- Philippe G Meyer, Claire Martinon, Stéphane Blanot, Gilles Orliaguet, Pierre Carli (19 December 2005)
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Prehospital Emergency intubations: Extended role of UK Trauma Anaesthetists.
- Sumit Kumar Jha, Dr Ashok Kumar BP, Ex-Registrar, Anaesthetics. LTMG Hospital, Mumbai. India. Dr Deepak Kumar. Ex-Registrar, Anaesthetics. LTMG Hospital, Mumbai. India. (19 December 2005)
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Philippe G Meyer, MD Dept Anaesthesiology Hopital Necker Enfants Malades Paris, Claire Martinon, Stéphane Blanot, Gilles Orliaguet, Pierre Carli
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To the Editor, Sir, We were very interested in reading Dr Mathias Helm and colleagues’ article published in the British Journal of Anaesthesia concerning factors influencing emergency tracheal intubation (ETI) in the pre-hospital setting-a multicentre stuffy in the German helicopter emergency medical service (1). This paper demonstrates clearly that emergency tracheal intubation, although performed in a quite hostile environment, can be safely and efficiently managed at the scene provided that skilled medical staff could be involved in prehospital management. It also clearly underlines the need for extensive clinical practice, better encountered in physicians, and anaesthesiology technicians, and for adequate use of anaesthesia induction prior to intubation. It completes two recent articles from this single team demonstrating that prehospital ventilation could result, in multiple trauma patients, where early adapted ventilation is so critical for further outcome, in normoxia upon arrival in 82% of the cases., and normocarbia provided that close monitoring could be used (2,3). These papers contrast dramatically with some others coming from North America, where EMT’s are responsible for ETI, experience difficulties in intubating trauma patients, and have a success rate remaining less than 50% when rapid sequence induction is not used prior to ETI (4). The situation could me more difficult in paediatrics, where ETI in the field could represent a real nightmare for most EMT’s. In Gausche and colleagues’ paper, comparing the efficiency of ventilation obtained with bag mask ventilation and ETI performed by theoretically trained paramedics, ETI was attempted by paramedics in only 73 % of the children allocated to ETI group, and successful in less than 43%. This creates a major bias precluding conclusions, and demonstrating the inadequacy of paramedics training in paediatric field intubation. Although the goal of this study was to demonstrate that bag-mask ventilation was similar to ETI in terms of mortality and outcome, the efficiency of ventilation was not evaluated in this study except by clinical observation of chest rise with positive pressure ventilation. The conclusion of this paper was that bag mask ventilation could be as efficient as ETI and ventilation in children, and safer to use in prehospital airway management of children (5). This conclusion differs from our own experience of prehospital pediatric intubation performed by trained physicians. In a series of 188 severely head-injured children, we found a 78% rate of successful pre-hospital intubation, raising to 98% in those with a scene GCS less than 8. Upon arrival, only 7,5% of the children who had associated severe chest trauma were hypoxic. Minor immediate complications like cough reflex, and multiple ETI attempts were noted in 25% of the cases, and were clearly correlated to inadequate use of anaesthesia induction prior to intubation, and lack of experience of the physician (6). We therefore do agree with Dr Helm that, despite far from optimal conditions of comfort, prehospital intubation can be performed safely and efficiently, in both adults and children, provided that adequate anaesthesia induction could be used by experienced physicians before intubation. The French recommendations for clinical practice published in 1998 state that “field intubation should be performed for all trauma patients with a GCS of 8 or less, by trained physicians after rapid sequence induction with etomidate and succinylcholine (7). These recommendations could be more adapted to modern clinical practice, and more adequate for gas exchanges in multiple trauma patients, than ordering bag-mask ventilation until hospital arrival because of the lack of trained personnel involved in field management. 1 Helm M, Hossfeld B, Schäfer S, Hoitz J, Lampl L. Factors influencing emergency tracheal intubation in the pre-hospital setting-a multicentre stuffy in the German helicopter emergency medical service. Br J Anaesth. 2005: 96: 67- 71. 2 Helm M, Hauke J, Lample L A prospective study of the quality of pre- hospital emergency ventilation in patients with severe head injury. Br J Anaesth. 2002;88:345-9 3 Helm M ,Schuster R ,Hauke J ,Lampl L . Tight control of prehospital ventilation by capnography in major trauma victims. Br J Anaesth. 2003 ; 90:327-32. 4 Wang HE, O’Connor RE, Megargel RE. The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp. Emerg Care 2000 ; 4 : 14-18. 5 Gausche M, Lewis RJ, Straton SJ. Effect of out of hospital pediatric endotracheal intubation on surival and neurological outcome. JAMA 2000 ; 283 : 783-90 6 Meyer PG, Orliaguet G, Blanot S. Complications of emergency tracheal intubation in severely head-injured children. Paed Anaesth 2000 ; 10 : 253-60. 7 Recommendations pour la pratique des transports extra-hospitaliers. Conférence de Consensus de la Société Française d'Anesthésie- Réanimation. Paris 1998. SFAR éditions. Paris Philippe G Meyer, Claire Martinon, Stéphane Blanot, Gilles Orliaguet et Pierre Carli Dept paediatric Anaesthesia CHU Necker Enfants Malades-Université Paris5 Paris Conflict of Interest:None declared |
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Sumit Kumar Jha, Senior House Officer, Anaesthetics. Pinderfields General Hospital, Wakefield. United Kingdom., Dr Ashok Kumar BP, Ex-Registrar, Anaesthetics. LTMG Hospital, Mumbai. India. Dr Deepak Kumar. Ex-Registrar, Anaesthetics. LTMG Hospital, Mumbai. India.
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We read with interest the well written article of M. Helm and colleagues on Factors influencing emergency intubations in the pre- hospital setting—a multicentre study in the German Helicopter Emergency Medical Service. They point out the significant number of pre-hospital deaths from trauma in the UK in which airway obstruction was thought to have contributed to death in up to 85% of patients. The study envisages an extended role of Anaesthetists in the Trauma team with ETI performed by the trauma anaesthetists, rapid sequence induction’ (RSI), with preoxygenation and cricoid pressure followed by an induction agent and then suxamethonium. They rightly point out that the on -field technique is more difficult because of a number of factors, such as limited equipment and monitoring, lack of skilled help, blood, vomit and debris in the upper airway, inadequate lighting, excessive noise and impaired patient access. Therefore, pre-hospital airway management is difficult, even for anaesthetists with extensive experience in airway management. I would like to point out that the German Helicopter Emergency Medical Service (HEMS) system, which is a physician based EMS system and the data from this study showed a significant proportion (65.6%) of problems encountered in difficult case scenarios could be potentially life -threatening. The authors found significant problems relating to Blood (19.9%), Vomit/debris (15.8), Hypersalivation (13.8%), Anatomy (11.7%) and Trauma related anatomical changes (4.4%). There are also lessons to be learnt from this study in relation to differences in staffing, treatment philosophy (sedation and neuromuscular blocking drugs were used in the present study), optimal/best attempt at conventional laryngoscopy made as early as possible with a reasonably experienced endoscopist, no significant muscle tone, optimal sniff position, the use of OELM in patients with laryngoscopic view grade either II, III or IV and the change of length of blade or type of blade. As far as lessons for the UK ambulance services in concerned, Waterloo headquarters is the largest ambulance control room in Europe. Some 3,000 emergency calls are received here every day. The London Ambulance Service uses the Advanced Medical Priority Dispatch System. In line with other UK ambulance services, emergency medical despatchers ask a series of structured questions so that 999 calls can be put into one of three categories: Red - immediately life-threatening; Amber - serious but not immediately life-threatening; Green - neither immediately life- threatening or serious. These codes correspond with the Department of Health's classifications of Category A, B and C. Corresponding to the authors experience with patient outcomes in relation to trauma and non- trauma ETI’s this may be a cue to more proactive participation of Anaesthetists, especially in the Category A calls. The NHS modernizing agency is striving to improve services in this direction. Improvement Partnership for Ambulance Services (IPAS) is a step in this direction. But there is a need for smaller, better trained and experienced personnel involved to have a good intubation success rate. This will also require a shift in perception to a physician-led and physician based ambulance service. Conflict of Interest:None declared |
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