Research In Airway Management Medic One Tuesday Series April 2009

1. Research In Airway ManagementMedic One Tuesday SeriesApril 2009 Keir J. Warner, BS Paramedic Training

2. JEMS March 2009 • “When paramedics were first introduced in the 1970’s, one of the most controversial aspects of their training program was endotracheal intubation.”

3. JEMS March 2009 • “…it was difficult to secure time when paramedic students could practice their intubation skills on live patients.”

4. JEMS March 2009 • “…many paramedics of that era were graduated without ever having the opportunity to perform an ETI.”

5. JEMS March 2009 • “…many paramedics of that era were graduated without ever having the opportunity to perform an ETI.”

6. JEMS “Is ETI the Gold Standard” • “Argues that failure to VENTILATE not failure to INTUBATE should be the gold standard.”

7. JEMS “What are the Success Rates” • In Florida 37% mis-placement rate • Non-cardiac arrest patients 58% 1st pass • Pediatric ETI only 78% • THE BEST DATA? • Western Washington • Bulger, et al. -98.4% • Wayne, et al. -95.5%

8. JEMS “Outcomes” • “Outcome studies in trauma patients fail to show benefit from ETI.” • “…not supported by evidence…” • “ETI… associated with similar or greater mortality than bag-valve mask ventilation alone.”

9. JEMS “OR Time & Field ETI” • “Half of paramedic training programs provide less than 16 hours of OR time.” • Average of 3.7 ETI per year • In another study, • 67% had 2 or less ETI per year • 39% had noneat all

10. JEMS “Alternatives” • “… paramedics had alternative airways that were as good as ETI, and perhaps safer.” • “…with the advent of (supra-glotic) airways that don’t require visualization of the airway, and have been found to be safe and effective, it’s hard to continue to justify continued routine ETI in prehospital care.”

11. JEMS “Accepting the Inevitable” • “Ironically, it is no the scientific evidence against prehospital ETI that is driving it out of EMS practice. It is simply the inability to properly educate students in… (ETI).” • “ETI, will probably be a thing of the past. We must embrace the current adjunct airways…”

12. Why Does Medic One Intubate ?

13. The Medic One Rule for Training “For us to perform an invasive procedure it must be as if a well trained physician is doing the procedure…”

15. ETI Success Rates 98.3% 3rd

16. Anatomic Features of the Difficult Airway

17. Problems Getting an Airway?

18. Difficult Airway Rescue Success

19. Airway Management Goals • Provide OXYGENATION (High Flow O2) • Prevent Hypoxia • Provide VENTILATION (Remove CO2) • PROTECTthe airway! • Aspiration • Obstruction

20. Airway Management Options • BLS • Spontaneous Respirations • High Flow O2 with NRB • May provide adequate Oxygenation, but what about Ventilation? • No Respirations • BVM with Oral Airway • Combitube/LMA • No Protection from Aspiration • Poor ability to ventilate

21. Airway Management Options • ALS • Protect, Oxygenate & Ventilate! • Oral Endotracheal Intubation • RSI with meds for GCS <8 • Monitor SpO2 for Oxygenation • No reliable way to judge ventilation in the multiply injured patient

22. Gold Standard RSI Monitoring: Pulse Oximetry & Expired CO2 • Prevent De-saturations During RSI • Capnography • Confirm the ETT, and monitor

23. Paramedic Training for Proficient Prehospital Endotracheal Intubation Keir J. Warner BS David Carlbom, MD Colin R. Cooke, MD, MSc Eileen M. Bulger, MD Michael K. Copass, MD Sam R. Sharar, MD

24. UWSOM PMT Program • 2,200 hrs of PMT • 400 hrs of lectures • 100 hrs of labs • 600 hrs of clinical • 800 hrs of field internship • 300 hrs of formal evaluation

25. Objective The goal of this study is to describe the relationship between the number of ETI experiences during initial paramedic student training and the likelihood of success on subsequent ETI attempts in the prehospital setting

26. Methods • A Retrospective Study • UWSOM Paramedic Training Program • Reviewed Prehospital “Blue Sheets” • Data into a database and analyzed • INCLUSION CRITERIA • Student Attempted Prehospital Intubation

27. Definitions ETI success was defined as any placement of an ETT that was confirmed to be within the trachea regardless of number of attempts • First pass success was defined as placement of an ETT within the trachea on the first ETI attempt

28. Results

29. Results

30. 100% 90% 80% 70% 60% 50% 5 10 15 20 0 Overall Success Prehospital ETI Success Rate First Pass Success Cumulative Prehospital Intubation

31. Limitations • Inability to record all OR intubation success rates • Only three years worth of data • Missing data on anatomic confounders

32. Where do we go from here? • Continue to track skill acquisition in the OR and Field settings • Increase opportunities for ETI during training • Continue to review and change our practices based on our evidence

33. Conclusions Odds of endotracheal intubation success increase with each cumulative exposure to ETI. First-pass placement of the endotracheal tube with high success rates requires high numbers of ETI that may exceed the number available in many training programs. The national curriculum recommendation of five successful endotracheal intubations is inadequate to produce appropriate prehospital ETI success rates and should be reconsidered.

34. Thanks ?