GETTING IT RIGHT

FIRST TIMEor

“Intubating Kiddies in Helicopters” Luke Regan

@lukeandrewregan

“60% of the time....it works every time!”WHO is referring to WHAT here?

Let’s start with a groovy MCQ

A) Noted airway expert Dr Minh le Cong describing use of cricoid pressure

B) Noted gaseous induction expert Brian Fantana describing use of “Sex Panther”

C) Noted oral sedation expert Dr John Glasheen

describing use of Guinness in fracture manipulations

D) Dr Hyuk Joong Choi (et al) describing the alarming

baseline rate of first pass success intubating

children across 13 Korean Emergency Departments

from 2006-2010

D) Dr Hyuk Joong Choi (et al) describing the alarming

baseline rate of first pass success intubating

children across 13 Korean Emergency Departments

from 2006-2010

Improving first pass success in emergency paediatric intubation

1 - WHY THIS MATTERS

2 – WE ARE ALL LIARS

3 – GET OUT YOUR SHOTGUNS

TAKE HOME POINTS

WHY FIRST PASS SUCCESS MATTERS

“Airways are like willies - the more you fiddle the harder they get....”

Dr Minh Le Cong

Sakles et al January 2013

1828 oral intubations

WHY FIRST PASS SUCCESS MATTERS

Intubationsuccess at....1st 2nd

3rd

or 4th attempt

14% 47%

63%

and 71%!

= complication rates of =

Even a single failed attempt resulted in over 3 times the rate of adverse events

So that’s all well and good in hospital...what about prehospital?

My hero

Göttingen Emergency Medical Service

Oh there’s Gottingen...

Eich et al 2009

FPS = 84.5%

 

OK numbers but....

Note the enthusiasm for nasal intubation!

WE ARE ALL LIARS

59 of the 114 patients (52%) were intubated on the first attempt.

Kerrey et al September 2012

Can we even be trusted to report accurately?

GSA HEMS Study

All recorded intubations on patients under the age of 16 years between 2009 and 2013.

53 patients identified Successful intubation rate of

100%.

But as we’ve discovered, that’s not the whole story....

Overall First Pass Success = 94.3% on all paediatric intubations

*Please note the word ‘Guarantee’ does not represent an actual guarantee

Intubationsuccess at....1st 2nd

3rd

or 4th attempt

14% 47%

63%

and 71%!

= complication rates of =

Intubationsuccess at....1st 14% = complication

rates of =

Thoughts

AIRWAY MARKSMAN? AIRWAY SHOTGUN!

vs

The literature has yet to comment on what happens when you force paramedics and doctors to:

AIRWAY MARKSMAN? AIRWAY SHOTGUN!

vs

The Endquestions?

REFERENCES (1) Harris T, Lockey D. Success in physician prehospital rapid sequence intubation: what is the effect of base speciality and length of anaesthetic training? Emerg Med J 2011 Mar;28(3):225-229. (2) Lossius HM, Roislien J, Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care 2012 Feb 11;16(1):R24. (3) Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med 2013 Jul 25;21:58-7241-21-58. (4) Bano S, Akhtar S, Zia N, Khan UR, Haq AU. Pediatric endotracheal intubations for airway management in the emergency department. Pediatr Emerg Care 2012 Nov;28(11):1129-1131. (5) Choi HJ, Je SM, Kim JH, Kim E, Korean Emergency Airway Registry Investigators. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study. Resuscitation 2012 Nov;83(11):1363-1368. (6) Green SM. A is for airway: a pediatric emergency department challenge. Ann Emerg Med 2012 Sep;60(3):261-263. (7) Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth 2012 Aug;22(8):729-736.

REFERENCES (8) Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med 2012 Sep;60(3):251-259. (9) Nishisaki A, Turner DA, Brown CA,3rd, Walls RM, Nadkarni VM, National Emergency Airway Registry for Children (NEAR4KIDS), et al. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med 2013 Mar;41(3):874-885. (10) Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013 Jan;20(1):71-78. (11) Sukys GA, Schvartsman C, Reis AG. Evaluation of rapid sequence intubation in the pediatric emergency department. J Pediatr (Rio J) 2011 Jul-Aug;87(4):343-349. (12) Gerritse BM, Draaisma JM, Schalkwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics perform paediatric tracheal intubation in the field? Resuscitation 2008 Nov;79(2):225-229. (13) Eich C, Roessler M, Nemeth M, Russo SG, Heuer JF, Timmermann A. Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians. Resuscitation 2009 Dec;80(12):1371-1377. (14) Sanders RC,Jr, Giuliano JS,Jr, Sullivan JE, Brown CA,3rd, Walls RM, Nadkarni V, et al. Level of trainee and tracheal intubation outcomes. Pediatrics 2013 Mar;131(3):e821-8. (15) R.Bloomer,B.Burns,S.Ware,K.Habig. Improving documentation in pre-hospital rapid sequence intubation. Emerg Med J. 2012 Apr 13