Intubation in the Field CON

1. Intubation in the Field CON Gregory H. Botz, MD, FCCM Professor of Anesthesiology and Critical Care

2. First Do No Harm!

5. Chapter IV INITIAL AIRWAY MANAGEMENT

6. Modern Medicine!

7. Congenital

8. Infections

9. “Space-Occupying Lesion”

10. Airway Management Outcomes Patients don’t die from failure to intubate, they die from failure to ventilate! John Campbell, MD Basic Trauma Life Support, ITLS

11. Out-of-hospital endotracheal intubation found to be associated with adverse outcomes for traumatic brain injury patients Agency for Healthcare Research and Quality (AHRQ) Out-of-hospital endotracheal intubation found to be associated with adverse outcomes for traumatic brain injury patients Current guidelines call for treating traumatic brain injury patients with aggressive measures to prevent hypoxia (insufficient oxygen reaching the body's tissues), including the use of endotracheal intubation. Controversial advanced airway management techniques, including use of neuromuscular blockade-assisted endotracheal intubation, make it possible for paramedics to perform out-of-hospital intubation of these patients. According to a recent study, individuals suffering from traumatic brain injury who are intubated by paramedics out of the hospital are four times as likely to die and nearly twice as likely to be functionally impairedas those who undergo the procedure in a hospital emergency department (ED). Wang HE, Peitzman AB, Cassidy LD, et al: Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Annals of Emergency Medicine 2004; 44:439-450.

12. Endotracheal Intubation Errors 1954 out-of-hospital Endotracheal Intubations: 444 (22.7%) patients experienced one or more ETI errors • Endotracheal tube misplacement or dislodgement in 61 (3%), • Multiple Endotracheal Intubation attempts in 62 (3%) • Failed Endotracheal Intubation in 359 (15%). 1196 (61%) cases linked to outcomes: • 872 (73%) died and 323 (27%) survived to hospital discharge. Wang HE, Cook LJ, Chang CC, Yealy DM, Lave JR: Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation. 2009;80:50-5.

13. Trauma: BVM vs. ETI • Few data exist supporting a survival benefit to prehospitalendotracheal intubation (ETI) over bag-valve-mask ventilation (BVM) in trauma patients. • 5,773 patients, 316 (5.5%) had ETI and 217 (3.8%) had BVM. • Patients receiving ETI were significantly more like to die (88.9% vs. 30.9%, p < 0.0001). • When corrected for Injury Severity Score, Revised Trauma Score, and mechanism of injury, ETI was associated with similar or greater mortality than BVM. • ETI patients had longer prehospital times (22.0 vs. 20.1 minutes, p = 0.0241) Stockinger ZT, McSwain NE: Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma 2004;56:531-6.

14. Bag-Valve-Mask vs. Endotracheal Intubation: No difference in outcome Less interruption Airway adjuncts are effective… Incidence of unrecognized misplaced ET tube: 6-14%!

15. Field Endotracheal Intubation Airway Adjuncts are an effective alternative to endotracheal intubation in the field…

16. Continuous Positive Airway Pressure

17. Continuous Positive Airway Pressure

18. Continuous Positive Airway Pressure • Prehospital CPAP reduced mortality by 18% and intubation by 16%. • Non-intubated patients had an average hospital stay of about five days versus 10 days for the intubated patient (five days of which are spent in the ICU at a cost of three to four times that of the general ward) • The number needed to treat (NNT) to avoid an intubation is 6. Hubble MW, Richards ME, Wilfong DA: Estimates of cost-effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehospital Emergency Care 2008;12:277-85.

19. Combitube

20. Laryngeal Mask Airway

21. Laryngeal Mask Airway

22. Laryngeal Mask Airway

28. Laryngeal Mask Airway

31. King Laryngeal Tube

32. King Laryngeal Tube

36. “Community Standard of Care”

37. Question 1 My clinical responsibilities includes endotracheal intubation. 1. True 2. False

38. Question 2 In the last 3 months, I have performed endotracheal intubation in the field: 1. None 2. 1- 3 times 3. 4-7 times 4. 8-10 times 5. > 10 times

39. Question 3 Which of the following is the most common method you use to maintain airway management competency? 1. OR/ ER/ ICU Intubations 2. Mannikin Intubations 3. Field Intubations

40. Question 4 After failed attempts at endotracheal intubation, my secondary airway management strategy is: 1. Oral airway and facemask 2. Bag-Valve-Mask ventilation 3. Laryngeal Mask Airway 4. Combitube / Laryngeal Tube 5. Surgical Airway

41. Question 5 A 58 year old male bicyclist collides with a 25 year old stationary leaf-bearing object along a bike trail. He was not wearing a helmet. He has multiple skin abrasions and a large hematoma on his forehead. He only localizes to tactile stimulation. GCS is 8. How would you manage? 1. Supplemental oxygen by facemask 2. Assisted ventilation with BVM 3. Airway adjunct placement 4. Rapid Sequence Intubation