Research In Airway Management Medic One Tuesday Series April 2009 Keir J. Warner, BS Paramedic Training

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.”

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

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

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

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

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

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.”

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 none at all

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.”

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…”

Why Does Medic One Intubate ?

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…”

ETI Success Rates 98.3% 3rd

Anatomic Features of the Difficult Airway Anatomic FactorsFrequencyPercentage Obese % Anterior Trachea % Distorting Facial Trauma75.8 % Short Neck % Large Tongue % FB/ Aspiration % Small Mouth % Stiff/Fused Neck %

Problems Getting an Airway?

Difficult Airway Rescue Success Method Attempted # Attempted# WorkedSuccess Rate Oral ETT % Nasal ETT100 % Digital ETT % Retrograde Intubation % Jet Insufflation % Cricothyroidotomy %

Airway Management Goals Provide OXYGENATION (High Flow O 2 ) –Prevent Hypoxia Provide VENTILATION (Remove CO 2 ) PROTECT the airway! –Aspiration –Obstruction

Airway Management Options BLS –Spontaneous Respirations High Flow O 2 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

Airway Management Options ALS –Protect, Oxygenate & Ventilate! –Oral Endotracheal Intubation RSI with meds for GCS <8 Monitor SpO 2 for Oxygenation No reliable way to judge ventilation in the multiply injured patient

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

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

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

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

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

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

Results Table 1N=56 Students ETI LocationN= Student ETIs Median (IQR) Operation Room (Adults)70613(11-14) Emergency Department711(0-2) Operating Room (Children)2635(3-6) Prehospital57610(7-13) Total Intubations161629(25-33) ETI= Endotracheal Intubation, IQR= Interquartile Range

Results Table 2 ETI TypeN= Percent of Prehospital ETIs ETI Per Student Median (IQR) Total Success Rate 1 st Pass Success Rate Cardiac Arrests %3 (2-4)88.6%63.4% Trauma %3 (1-4)87.8%63.5% RSI %6 (5-9)88.3%67.7%

100% 90% 80% 70% 60% 50% Overall Success First Pass Success Cumulative Prehospital Intubation Prehospital ETI Success Rate

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

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

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.

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