Note: Abstracts may be downloaded as a single PDF using the link below.
Prehospital Narcotic Analgesia among Burn Patients
Author: Melinda Pendleton, EMT-B
Associate Authors: Gabby Robinson, EMT-B, David Stallings, EMT-B, Evelyn Wilson, MHS, NREMT-P, Kaleigh Reddick, EMT-B, Sara Houston, BS, NREMT-P, Scott Lodge, AAS, EMT-P, Anthony Davidson, EMT-P, Randy Kearns, DHA, MSA, NREMT-P , Michael Hubble, PhD, MBA NREMT-P
Introduction: In the prehospital setting, appropriate pain management remains a concern. Literature suggests that inconsistencies exist in the out-of-hospital setting related to pain control among certain patient populations. It is possible that prehospital care providers are more sensitive to administering narcotics to burn patients for pain management as opposed to other traumatic injuries, although this has not been previously explored.
Objective: To estimate the likelihood of burn patients receiving prehospital narcotic analgesia (Dilaudid, fentanyl, Demerol, and morphine).
Methods: A retrospective analysis was conducted using data from the North Carolina Prehospital Care Reporting System (PreMIS). The sample represented statewide data from July 31t to December 31, 2012. The inclusion criteria consisted of patients older than 14 years who suffered a traumatic injury or burn, had a documented pain score, had a Glasgow coma score of at least 12, and were transported by EMS. A logistic regression model was used to analyze the likelihood of narcotic analgesia administration to patients with burn injuries vs. patients with nonburn injuries, controlling for pain severity and other variables identified by previous studies as potential confounders (age, gender, race, pain score, and total prehospital time).
Results: A total of 38,848 patients met the inclusion criteria. Burn patients were 6.4 times more likely to receive narcotic analgesic intervention (OR = 6.35, p < 0.01) than patients with any other mechanism of injury. Females (OR = 0.73, p < 0.01), and minorities (OR = 0.50, p < 0.01) were less likely to receive narcotic analgesia. Patients with higher pain scores (OR = 1.49, p < 0.01) and longer total prehospital times (OR = 1.02, p < 0.01) were more likely to receive prehospital narcotic analgesia. Age was also associated with a statistically significant but clinically irrelevant increase in the likelihood of narcotic pain control (OR = 1.003, p < 0.01).
In this retrospective analysis of a statewide EMS database, prehospital providers were more likely to administer narcotic analgesics to burn patients compared to patients with nonburn injuries. Similar to other studies, females and minorities were less likely to receive narcotic analgesia.
EMS Lactate as a Predictor of Mortality in Medical Patients
Author: Ryan Mayfield, MS, NREMT-P
Assoicate Author: Mary Meyers, MHA, EMT-P
Introduction: The severity of hypoperfusion may be underestimated when evaluating a patient using blood pressure alone. Several studies have looked at the relationship between lactate and mortality in trauma patients. However, this relationship has not been established for medical patients.
Hypothesis: The highest EMS lactate will be a better predictor of mortality than the lowest systolic blood pressure or the lowest mean arterial pressure.
Methods: This prospective study was IRB approved and given a waiver of informed consent for research in emergency settings. In November 2008, about 950 EMTs and paramedics were trained to identify patients with cryptic shock and evaluating blood lactate levels. To measure blood lactate levels, paramedics were provided with the Lactate Proc blood lactate meter by Arkray Inc. This meter is FDA approved, CLIA waived, and has been shown to correlate well with standard laboratory measurements in humans and animals using enzymatic colorimetric and blood gas analyzers as the gold standard. Between November 1, 2011 and December 31, 2012, patients who were older than 18, who were not pregnant, and who had suspected shock underwent blood lactate readings by EMS. Patients with a lactate reading of â‰¥ 4.0 mmol/L were considered to be in shock even if their corresponding systolic blood pressure was above 90 mmHg.
Results: During the study period, 241 patients with prehospital lactate measurements were matched with hospital records to determine patient outcome. Out of the 241 patients, 17 (7.1%) expired in the hospital. Out of the three variables tested, only the prehospital lactate reading had a significant predictive value (crude OR = 1.25, 95% [I assume] CI 1.02 to 1.42, p = 0.029). Neither systolic blood pressure nor mean arterial pressure had a significant relationship to mortality (p = .225 and .409, respectively).
Conclusion: In this study, it is clear that blood pressure alone is not a good predictor of mortality and may lead to under estimating the severity of a patient without the use of lactate. Future studies are needed to determine if this relationship remains in a larger population with more diverse disease processes.
Variations in the Frequency and Nature of Feedback Paramedics Receive from their Medical
Author: Dr. Elliot Carhart, EdD, RRT, NRP, NCEE
Associate Authors: Christopher Shane Henderson, BS, EMT-P
Introduction: In 2010, the American Board of Medical Specialties recognized EMS as a subspecialty of emergency medicine. Despite this milestone, little is known about the interactions between EMS medical directors and the paramedics they supervise.
Objective: To characterize the perceptions of paramedics regarding interactions with their medical director.
Methods: This survey study was approved by the Carilion Clinic IRB and was distributed via SurveyMonkeyâ„¢. Participants were recruited from a convenience sample of paramedics across the United States. The survey instrument included 22 questions focused on the perceptions of various aspects of interaction with their medical director. Pearson Chi-square tests were used to analyze the data.
Results: The authors received 446 unique responses that met the inclusion criteria; 18 incomplete responses were excluded for a total N of 428. A series of Pearson Chi-Square tests revealed significant differences in the frequency and nature of feedback paramedics have received from their medical director. The majority of participants who transport patients to a facility where their medical director works (63%, n=184) reported that they have received positive feedback from their medical director, compared to 52% (n=72) [if this is a subset of another number, that needs to be given.]of participants who do not transport to such a facility (X2=4.945, df 1, p=0.026). A significant majority of participants who have run an EMS call with their medical director (89%, n=101) also reported that they have received positive feedback from their medical director, compared to only 49% (n=155) [if this is a subset of another number, that needs to be given.]of participants who have never run a call with their medical director (X2=53.558, df 1, p<0.001). While transport destination does not appear to be related to the frequency of negative feedback, there is a significant difference in the frequency of negative feedback associated with medical director interaction on an EMS call. Only 35% of participants (n=110) who have never run an EMS call with their medical director indicated they have received negative feedback from that individual, compared to 56% of participants (n=64) who have run an EMS call with their medical director (X2=15.446, df 1, p<0.001).
Conclusion: The results of this study show significant differences in the frequency and type of feedback paramedics received from their medical directors. Further investigation should focus on identifying the effects of such feedback on relevant aspects of patient care.
Epidemiology of Statewide Prehospital Pain Control in North Carolina
Author: Stephen Taylor, BS, EMT-P
Associate Authors: Lee Van Vleet, MHS, NREMT-P, Doug Campbell, EMT-P, James Thomson, EMT-P, Chelsea Cardwell, EMT-B, Kristen Johnson, EMT-B, Michael Hubble, PhD, NREMT-P, Susan Crisp, EdD-C, NREMT-P, Melisa Martin, MHS, EMT-P
Introduction: Recent studies suggest socio-economic disparities in pain management among emergency departments and prehospital patients, in particular, age, race and gender. However, such disparities have not been thoroughly investigated on a statewide basis among prehospital trauma patients.
Objective: To determine the factors that influence paramedics’ pain management decisions for prehospital trauma patients.
Methods: This study is a retrospective observational study of prehospital pain control using the North Carolina Prehospital Care Reporting System (PreMIS) data from July 1 to December 31, 2012. The North Carolina Office of Emergency Medical Services 2009 standardized protocols were the basis of pain medication administration. Inclusionary criteria consisted of trauma patients with a first pain score â‰¥7. The analgesics of interest included acetaminophen, ibuprofen, morphine sulfate, hydromorphone, ketorolac or fentanyl. Logistic regression was used to calculate the adjusted odds ratios for factors (patient age, gender and race, and total prehospital time) associated with the administration of analgesia.
Results: A total of 17,294 patients met the inclusionary criteria. Compared to adults, pediatric patients (â‰¤18 years) were more likely to receive pain medication (OR = 1.24, p< 0.01),[ORs are typically presented with their 95% CIs; please provide.] while geriatric patients (â‰¥65 years) were no more likely to have receive pain medication than adults (OR = 1.07, p=0.14). Non-Caucasians were less likely to receive pain medication compared to Caucasians (OR = 0.57, p<0.01) and compared to males, females were less likely to receive pain medication (OR = 0.80, p<0.01). Using the abdominal region as the reference category, patients with lower extremity trauma and upper extremity trauma were three times more likely to receive initial pain control (OR = 3.36, P<0.01 and OR = 3.14, p<0.01 respectively), while patients with head and neck pain were less likely to receive pain medication (OR = 0.459, p<0.01; OR = 0.435, p<0.01 respectively). Each additional minute of total prehospital time was an independent predictor of pain control (OR = 1.02, p<0.01).
Conclusion: This study found similar disparities in North Carolina prehospital pain management practices among trauma patients as studies suggested based on race and gender. Pediatric patients were more inclined to receive analgesia than adults. The frequency of pain management increased as prehospital times increased.
Does the Implementation of an ALS Quick Response Vehicle in an Integrated Fire/EMS System Improve Patient Contact Response Time?
Author: Dr. Dustin Anderson, NREMT-P, MD
Introduction: Patient response time is key to providing emergency medical care. Patient response time might be positively affected by faster ALS response via a quick-response vehicle strategically located in a geographic area.
Objective: The goal of this study was to determine if patient response times would decrease by placing an ALS quick response vehicle in an integrated fire/EMS system.
Methods: Response times from an integrated fire/EMS system with an annual EMS call volume of 3,261, were retrospectively evaluated over the three years before the implementation of this study. For a two -month period, an ALS quick response vehicle staffed by a firefighter/paramedic responded to emergency calls during peak call volume hours of 0800 to 1700. The staging of this vehicle was based on historical call volume percentages using respective geocodes as well as system requirements during multiple emergency dispatches.
Results: For the 12 months before the start of the study, the citywide average response time was 5.44 minutes. During the study, the citywide average response time decreased to 4.09 minutes, a 27.62% reduction in patient response time.
Conclusion: The implementation of an ALS quick response vehicle in an integrated fire/EMS system reduces patient response time. Having a quick response vehicle that is not continuously staged in a traditional fire station or municipal location reduces the time needed to reach patients. Using predictive models of historic call volume can aid fire and EMS administrators in reduction of call response times.
Association Between Duration of Symptoms and Nontransport Among Patients With Nontraumatic Complaints in an Urban EMS System
Author: Michael Gerber, MPH, NREMT-P
Associate Author: Larissa May, MD
Introduction: Previous research has examined characteristics of EMS patients who are not transported with a focus on the risk of nontransport, but questions remain as to why patients refuse transport.
Objective: The purpose of this study was to examine the association between the duration of symptoms before calling EMS and whether the patient is transported.
Methods: The authorsconducted a retrospective analysis of prehospital patient records in an urban ALS system. Duration of symptoms was defined as less than or more than 1 hour1 hour. Bivariate (Chi-squared and student’s t-test) analyses and multiple logistic regression were used to examine predictors of nontransport. [What are they compared to — transported patients?]
Results: In the bivariate analysis, nontransported patients were more likely to have had symptoms for less than 1 hour (76.7% vs. 42.7% for transported patients, p<0.0001). They also were younger (51 vs. 57 years old, p <0.0001); less likely to have a language barrier (2.6% vs. 4.6%, p <0.0001); and more likely to be under the influence of drugs or alcohol (10.1% vs 8.6%, p = 0.040). The regression analysis shows that for several patient complaints, patients with symptoms less than 1 hour were more likely to be nontransports. Those complaints included abdominal pain (OR = 8.61, 95% CI 4.59-16.16); musculoskeletal pain (OR = 4.12, 95% CI 2.21-7.68;, and respiratory problems (OR = 5.85, 95% CI 3.55-9.64).
Conclusion: Experiencing symptoms for less than 1 hour was associated with nontransport in most categories of patient presentations. Further research should examine whether the duration of symptoms and other factors can be used to determine the appropriate EMS response and patient disposition.
Prehospital Use of IV Fluids in Trauma Patients
Author: Caitlyn Boyles, AS, EMT-B
Asscoiate Authors: Sharon Schiro ,PhD, EMT-B, Chelsie Danye, EMT-B, Ryan Grebe, BS, NREMT-P, Eric Mayhew, BS, NREMT-P, CICP, Thomas Whalen, BS, EMT-B, Tobias WIlkie, EMT-B, Michael Hubble, , PhD, NREMT-P
Introduction: Appropriate fluid administration for the trauma patient is critical for patient outcome. Recent studies reported better outcomes for patients given IV fluid in the prehospital setting. Conversely, excessive fluid resuscitation in patients with traumatic injuries has been correlated with a poor patient outcome. Previous studies have suggested that permissive hypotension is directly correlated with better patient outcome.
Objective: To evaluate the appropriate application of prehospital fluid resuscitation of trauma patients.
Methods: A retrospective study of trauma patients treated between July 1 and December 31, 2012, was conducted using the North Carolina Prehospital Care Reporting System (PreMIS). Inclusionary criteria consisted of age older than 12 years, receipt of IV fluids, and transport to a destination of “hospital.” Exclusionary criteria consisted of incomplete patient care reporting, a burn injury, refusal of care, dead at scene, or care transferred to another prehospital provider. Chi-square analysis was used to determine the differences in the use of fluids vs. appropriateness of use for several anatomical areas of injury (head, chest, abdominal or extremity). Appropriate use of fluid was defined as patients who had an initial systolic BP <90mmHg and final systolic BP <140mmHg.
Results: A total of 23, 983 patients met the inclusionary criteria. Overall, 2.7% (n=648) of patients received appropriate fluid administration. The breakdown is: head injuries = 2.0% (p=0.02); chest = 2.8% (p=0.8); abdomen = 3.8 % (p=0.04); and extremity = 2.0% (p=<0.0001). [is the breakdown a % of all patients or a percent o f the 2.7%; add in the actual N for clarification.] Of patients with an indication of extremity venous access, only 20% had information in the chart indicating administration of normal saline. Ninety percent of the records indicated fluid was administered but did not indicate the volume given.
Conclusion: Due to the inconsistent method of reporting fluid administration, the appropriateness of prehospital administration of IV fluids could not be effectively evaluated. Therefore, at this time this study cannot conclude whether prehospital care providers are appropriately managing their trauma patients’ fluid administration. Further research will be needed to obtain more consistent data for analysis.
Determinants of EMS On-Scene Time for the Trauma Patient
Author: Sarah Harty, EMT-B
Associate Authors: Dean Wills, EMT-B, Joshus Lail, EMT-B, Melisa Martin, MHS, EMT-P, Candi VanVleet, MBA, DHAc, NREMT-P. Michael Hubble, PhD, NREMT-P
Introduction: Current research suggests that shorter total prehospital times are associated with increased survival among severely injured trauma patients. Total prehospital time consists of EMS response time, time on-scene and transport time. Assuming that ambulance response and transport times are relatively fixed components of the total prehospital time, only the on-scene time is amenable to change. Therefore, it is important to note the factors that determine on-scene times.
Purpose: To identify the determinants of EMS on-scene times.
Methods: A retrospective observational study of trauma incidents was conducted using the North Carolina Prehospital Care Reporting System (PreMIS). Incidents involving a single trauma patient who was treated and transported to a hospital by ground EMS between July 1to December 31, 2012, were included. Patients requiring extrication were excluded. Linear regression was used to analyze the influence of selected variables on the total on-scene time of trauma incidents. The variables included: pediatric patients (<18 years of age); spinal immobilization; MAST application; application of basic and traction splints; placement of an blind insertion airway device (BIAD); or endotracheal intubation; IV or IO attempt; chest decompression; presence of cardiac arrest; and the initial revised trauma score.
Results: A total of 69,454 patients met the inclusionary criteria. Overall, the average total on-scene time was 16.02 (±SD= 9.37) minutes. The following interventions increased total on-scene time: spinal immobilization (1.37 min, p< 0.01); basic splinting (2.14 min, p<0.01); traction splinting (9.48 min, p<0.01); BIAD placement (4.13 min, p=0.01); endotracheal intuation (3.87 min, p=0.01); IV access (3.96 min, p<0.01);, and IO access (4.4 min, p<0.01). Scene times were shorter with each incremental increase in revised trauma score (-0.59 min, p<0.01) as well as for pediatric patients (-1.26 min, p<0.01).
Conclusion: This study identified incremental changes in on-scene times associated with patient characteristics and prehospital treatments. With the exception of traction splinting, on-scene times were lengthened to a greater extent with ALS as compared to. BLS procedures. These results can be used to educate EMS personnel regarding the time trade-off of prehospital procedures, particularly those that can be performed after leaving the scene.
Montana Advanced Airway Study
Author: Steven Glow, MSN, FNP, EMT-P
Associate Author: John Bleicher, RN
Introduction: Meta analysis has shown that prehospital advanced airway maneuvers implemented in urban centers have a lower success rate than desired. Less is known about the success of prehospital advanced airway maneuvers performed in rural areas. The Montana Advanced Airway Study (MAAS) was designed to determine the frequency, provider choices and outcomes of advanced airway insertions by prehospital providers practicing in rural settings.
Methods: This is a prospective, descriptive, voluntary participation study using adapted protocols from the Denver Metro Airway Study Group (DMASG, 2009) to assess the success of prehospital advanced airway maneuvers implemented in a rural state. The data collection card developed by DMASG was modified with one side for EMS to document attempt(s); the other side of the card was used for ED confirmation of placement. Additional data collected were alternative device usage and confirmation methods. Any EMS provider who passed (or attempted to pass) an endotracheal tube or Supraglottic airway was requested to complete one side of the card and the ED provider assessed tube status and documented the findings on the card. Cards were then mailed to the researchers for descriptive analysis.
Results: Of the 157 cards received in one year, 101 (64.3) had both sides complete. Type of device on arrival in ED: ET tube 82%; Supraglottic airway 18%. Success rates on ED arrival: ET tube 98%/Supraglottic airway 95% (1 failure for each type of device). The overall first pass success rate regardless of device used was 78%. Type of device used on first attempt/success rate: ET tube 89%/74%; Supraglottic airway 11%/82%. Second attempt device used/success rates were: ET tube 83%/63%; Supraglottic airway 17%/75%. Confirmatory methods used were (prehospital/hospital): auscultation 91%/95%; visual 72%/58%; waveform capnography 55%/40%; O2 saturation 46%/34%; colorimetric capnography 28%/27%.
Conclusion: Supraglottic device success rates were higher on both first and second attempts compared to ET tubess. EMS providers did not rapidly switch to an alternative device if the first attempt was unsuccessful. EMS used confirmatory methods other than auscultation more frequently than the ED. Success rates for all devices were higher than other studies raising the question of selection bias.
References: Denver Metro Airway Study Group (2009) Prehosp Em Care.13:304-310.
Divert Status and Ambulance Transports: Is There a Relationship between EMS Perception and ED Volumes?
Author: Mary Meyers, MS, PM
Associate Authors: Connie Zachrich, MS, BS, Anne Clouatre, MS, BS
Introduction: Recent research is suggesting ED diversion status delays ambulance turnaround times and therefore increases time to availability for another call. This suggests EMS crews will avoid EDs with higher levels of divert or advisory status. Little research exists demonstrating a significant association between divert/advisory status and EMS transport volumes. This study looked at how ED divert or advisory affected transports in an urban and suburban hospital.
Hypothesis: ED divert or advisory has no effect on transport volumes.
Methods: Data were collected on aggregate transport volumes, divert hours for both ED and psychiatric advisory, and inpatient admits for a 5-year period from January 2008 to December 2012. Data were stratified by month and year for two hospitals, one urban with a psychiatric ED and one suburban hospital Level II trauma center. Both hospitals had 120 observations. Both are also part of the same hospital system and each receives more than 50% of total EMS patient volume from two respective transport agencies. Analysis used OLS and instrumental variables [needs further explanation on the analysis tools used].
Results: There was a significant negative association between monthly EMS transport volumes and monthly hours of ED or psychiatric advisory within the urban hospital (p = 0.001), and a significant negative association between monthly EMS volumes and ED divert in the suburban hospital (p = 0.009).
Conclusions: There is a significant association between hours of divert and transport volumes. Any divert status will affect transport decision and volume. Implications for EMS are prolonged transport times to alternate hospitals; economic consequences associated with longer out of service times; and decreased satisfaction for both EMS provider and hospital. As many regions have specific types of divert status, these results may not be generalizeable without adjusting for system differences.
A Comparison of Prehospital Vascular Access Methods, Success Rates, and Influence on Scene Times
Author: Daniel Wesley, BS, NREMT-P
Associate Authors: Ginny K. Renkiewicz, BS, EMT-P, William D. Medinas, EMT-B, Christopher A. Warr, NREMT-P, CICP, Rebecca J. Shepard, EMT-I, Katherine S. Vornheder, EMT-B, Theodore R. Morgan, BS, EMT-P, Michael W. Hubble, PhD, NREMT-P
Introduction: Currently intraosseous (IO) cannulations are considered a secondary intervention following a failed peripheral intravenous (IV) attempt. While numerous studies have examined cannulation times and success rates for either IV or IO, the comparative success rates for these two modalities and their influence on prehospital scene times has yet to be quantified.
Objective: To compare the first attempt success rates of two common vascular access modalities and their influence on scene times.
Methods: The authors conducted a retrospective observational analysis of trauma patients using the North Carolina Prehospital Care Reporting System (PreMIS) from July 1to December 31, 2012. Inclusionary criteria consisted of trauma patients more than 18 years old who received either a peripheral IV or an IO cannulation and were transported to a hospital by EMS. Excluded were those patients requiring extrication, or whose primary provider impression was obvious death, cardiac arrest or unknown. Chi-square tests were used to analyze success rates for IV and IO cannulation performed on-scene vs. during transport. Scene times were compared by setting (on-scene vs. during transport) using unpaired t-tests.
Results: A total of 21,670 patients met inclusion criteria, of which 21,544 (99.4%) received an IV attempt and 126 (0.5%) received an IO attempt. First attempt IV success rates were 80% on scene and 82.1% during transport (p <0.01), while first attempt IO success rates were 92.4% on scene and 90.0% during transport (p = 0.869), indicating statistically equivalent success of IO cannulation by setting. Mean on-scene times for cannulation performed on scene vs. those initiated during transport were 20.6 vs. 14.3 minutes for IV (p < 0.01) and 26.9 vs. 13.0 minutes (p < 0.01) for IO.
Conclusions: There is statistical significance in IV success rate by setting. However, the effect size is small and it is possible that the difference is not clinically relevant compared to the delay in initiating transport. Our results suggest that in trauma patients for whom IO access has been deemed appropriate, IO cannulation during transport limits total scene time while maximizing the potential for obtaining vascular access.
Video Laryngoscopy Enables Excellent CPR Quality in Cardiac Arrest
Author: Dr. Kevin Seaman, MD, FACEP
Associate Authors: Kenneth P. Rothfield, MD, Matthew J. Levy, Matthew, DO, MSc, John D. Jerome, BA, NREMT-P, Joseph E. Pellegrini, PhD, CRNA, Michelle H. Duell, CRNA, DNP, Cassandra M. Godar, BS, NREMT-P
Introduction: Endotracheal intubation has been recognized as a common cause of interruptions in CPR during cardiac arrest. A prehospital trial of video laryngoscopy was initiated with the goal of improving out-of-hospital cardiac arrest outcomes and overall quality of CPR by EMS providers. This study focused on the analysis of the impact of video laryngoscopy on frequency and duration of associated interruptions in CPR.
Methods: From January 2011 to April 2013, cases of adult, nontraumatic cardiac arrest in a suburban, fire-based EMS system were evaluated for use of video laryngoscopy. Intubation confirmation in the field was accomplished with real-time waveform capnography, video capture of the intubationattempt, and confirmation from the receiving EDphysician. Video laryngoscopy recordings were reviewed to identify evidence of CPR during the intubation attempt and interruptions in compressions. CPR analytics software was used to determine CPR fraction and duration of CPR interruptions when video evidence of compressions was not available.
Results: For this study, 144 of 326 (44.2%) cardiac arrest incidents in the study period involved the use of video laryngoscopy and met inclusion study criteria. EMS providers did not pause compressions for intubation attempts at any point in 68% of studied cases (n = 98). Of cases in which CPR was interrupted (n = 46), the mean number of interruptions was 1.3 (range 1-3). The mean total duration of ET intubation-associated CPR interruptions (n=60) was 44.4 seconds (CI 36.3-52.5). In cases in which CPR analytics was available (n=30), the mean CPR fraction was 87.6% (CI 84.7-90.6).
Discussion: The use of video laryngoscopy in cardiac arrest patients resulted in a low number and duration of interruptions in CPR compressions. Excellent CPR fraction was demonstrated for victims of cardiac arrest who were intubated by video laryngoscopy.
Determinants of Success and Failure in Prehospital Endotracheal Intubation
Author: Lucas Myers, BAH, NREMT-P
Associate Authors: Charles G Gallet, BA, NREMT-P, Logan J Kolb, BS, Christine M Lohse, MS, Christopher S Russi, DO, FACEP
Introduction: Endotrachel intubation in the prehospital setting is not always successful. Determining what makes an intubation successful could help prehospital care providers develop better techniques.
Objective: To evaluate endotracheal intubation performance of a multisite EMS agency to identify factors associated with rates of success and failure.
Methods: The authors analyzedET intubation attempts made from January to May 2010 by paramedics and other EMS crew members at a single agency consisting of 10 satellite sites in Minnesota and western Wisconsin. Electronic notification was sent to a study team member after each attempt. If documentation was incomplete, the study team contacted the paramedic to obtain required information. Paramedics use the current National Association of EMS Physicians’ definition of an intubation attempt (laryngoscope blade entering the mouth).
Results: During 12,527 emergent ambulance responses, 150 (1.2%) adult and pediatric patients underwent 200 intubation attempts. Of the 150 patients, 113 (75.3%) were successful and 37 (24.7%) were unsuccessful. A paramedic/paramedic crew was more than 3 times as likely to achieve successful intubation than a paramedic/EMT crew (OR = 3.30 [p=.03]). A small tube of 6, 6.5 or 7 inches was associated with a more than four-fold increased likelihood of successful intubation compared with a large tube of 7.5 or 8 inches (OR = 4.25 [p=.012]). After adjustment for these features, a partial (“some”) or whole (“entire”) view of the glottis was associated with a nearly 13-fold and a nearly 40-fold increased likelihood of successful intubation, respectively, compared with no or little view of the glottis (ORs = 12.98 [p=.001] and 39.78 [P<.001], respectively).
Conclusion: In this cohort of prehospital airway management cases, successful endotracheal intubation was most likely to be accomplished when the paramedic had some or an entire view of the glottis.