Airway management in the prehospital setting
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Airway management in the prehospital setting. Dr X.Combes, SAMU du Val de Marne, Créteil, France. Airway management in the prehospital setting. Dr X.Combes, SAMU du Val de Marne, Créteil, France. Why airway control is mandatory out of hospital?. Airway protection Coma Sedation

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Airway management in the prehospital setting

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Airway management in the prehospital setting

Airway management in the prehospital setting

Dr X.Combes, SAMU du Val de Marne, Créteil, France


Airway management in the prehospital setting

Airway management in the prehospital setting

Dr X.Combes, SAMU du Val de Marne, Créteil, France


Why airway control is mandatory out of hospital

Why airway control is mandatory out of hospital?

  • Airway protection

    • Coma

    • Sedation

  • Respiratory assistance with positive pressure ventilation

    • Respiratory distress

    • Cardiopulmonary rescucitation

  • Limitation or prevention of evolutive injury :

    • severe head traumatism

  • Winchell Rj et col; Arch Surg 1997

    Gentleman D et col; Lancet 1990


    Indications for prehospital tracheal intubation

    Indications for prehospital tracheal intubation

    Jabre P, SFAR 2003

    Adnet F,Ann Emerg 1998

    Ricard-Hibon A, Eur J Anaesthesiology 2002


    Characteristics of extrahospital airway management

    Characteristics of extrahospital airway management

    • Emergency context

      • Hostile environnment

      • Non cooperative patients

      • Poor knowledge of medical patients history

      • Not much time to upper airway evaluation

      • Risk of pulmonary aspiration

      • Interaction between patient and operator body position


    Potential adverse physical interaction between patient and operator

    Potential adverse physical interaction between patient and operator


    Medical conditions and anatomical abnormalities may induce difficult laryngeal visualization

    Medical conditions and anatomical abnormalities may induce difficult laryngeal visualization.....


    Incidence of failed prehospital intubation

    100

    80

    60

    failure

    40

    success

    20

    0

    Incidence of failed prehospital intubation

    100

    80

    60

    Intubations (%)

    40

    20

    0

    a

    b

    c

    d

    e

    f

    g

    h

    i

    j

    k

    l

    a : Stewart 1994 (n = 779)

    b :Pointer 1988 (n = 383)

    c : Krisanda 1992 (n = 278)

    d : Sayre 1998 (n = 103)

    e : Hedges 1988 (n = 310)

    f : Thompson 1994 (n = 862)

    g : Cantineau 1997 (224)

    h : Adnet 1998 (n = 691)

    i : Orliaguet 1997 (n = 157)

    j : Adnet 1997 (n = 394)

    k : Ricard-Hibon 1997 (n = 147)

    l : Adnet 1997 (n = 311)


    Influence of the sedation technique on intubation difficulties

    Influence of the sedation technique on intubation difficulties

    Adnet F; Eur J Emerg Med 1998


    Effect of a rsi protocol introduction in a medical prehospital unit

    Effect of a RSI protocol introduction in a medical prehospital unit

    Ricard-Hibon A et col; Eur J Anaesthesiol. 2002


    Rsi helps paramedics too

    100

    *

    Without RSI

    80

    (n=100)

    60

    Successful intubations

    40

    With RSI

    20

    (n=100)

    0

    RSI helps Paramedics too…

    • Extrahospital paramedic heliported unit

    • Introduction of a RSI protocol in daily practice

    • Assessment of successful tracheal intubation

    Rose WD; Air Med J. 1994


    Orotracheal or nasotracheal intubation

    Orotracheal or Nasotracheal intubation?

    Dronen SC et col;Ann. Emerg Med 1987 


    Influence of operator position when patient is lying on the ground

    Influence of operator position when patient is lying on the ground

    Adnet F, Can J Anaesth 1998


    Airway management in the prehospital setting

    BURP backward, upward, rightward laryngeal pressure

    60% Cormack III => II

    BURP > BACK

    Knill R; Can J Anaesth 1993


    Bougie and stylet

    Bougie and stylet

    • First use in 1943 by Macintosh

    • Successful blind tracheal intubation confirmed by tactile sensation

    • Helpful for patient with cervical immobilisation

    • Standard of practice in US emergency dpt

    • Rigid with little flexibility

    • Potentially traumatic for larynx and trachea


    Success rates of geb and stylet assisted intubation in cormack grade 3 patients

    Success rates of GEB and Stylet assisted intubation in Cormack grade 3 patients

    *

    *

    Gataure PS; Anaesthesia 1996


    Use of gum elastic bougie for prehospital difficult intubation

    Use of Gum Elastic Bougie for Prehospital Difficult Intubation

    • Observationnal study during 30 months

    • 1442 intubations

    • 42 uses of GEB

    • Success rate : 80%

    • 60% of patients had associated factors for DI

      • ENT neoplasy

      • Morbid obesity

      • Cervical reduced mobility

      • Facial trauma

    Jabre et al; submitted


    Pharyngeal artificial airways in extrahospital setting

    Pharyngeal artificial airways in extrahospital setting

    • Pharyngeal / oesopharyngeal

    • Single / double cuff

    • Single/double lumen

    • Allowing or not blind intubation


    Combitube

    Combitube

    • Often used as first airway device during CPR in paramedic system

    • Several extrahospital cases of difficult airway in trauma patients resolved with Combitube

    • Successful insertion by paramedics in 95% of patients with extrahospital difficult airway

    Davis DP and al; Ann Emerg Med. 2003

    Blostein PA and al; J Trauma. 1998


    Airway management in the prehospital setting

    LMA

    • Proposed as initial method of airway control during CPR

    • Particulary interesting in the difficult intubation and difficult ventilation scenario

    • Several case reports of prehospital difficult airway resolved with LMA have been reported

    Greene MK and col, Anaesthesia 1992

    Martin SE and al;The journal of trauma: 1999


    Airway management in the prehospital setting

    ILMA

    • ILMA, first described in 1997 has become a cornerstone of the in operating room difficut airway

    • Some case reports in prehospital settings have been reported

    • Its use with high success rate needs probably a minimal initial training

    Gibbs M and al; Acad Emerg Med 2003

    Combes and al; Ann Emerg Med 2004


    Training with ilma on manikin

    Training with ILMA on Manikin


    New airway devices

    New airway devices

    • CobraPLA™

      (PerilaryngealAirway)

    • PAxpress™

    • Laryngeal tube™


    Cricothyroidotomy

    Cricothyroidotomy

    • Ultimate Airway management strategy

    • Frequently used in North American prehospital paramedical system

    • Success rate : 80-100%

    • Major complications : 10%


    What is the minimum training required for successful cricothyroidotomy a study in mannequins

    What Is the Minimum Training Required for Successful Cricothyroidotomy?: A Study in Mannequins

    • 102 anesthesiologists

    • Vidéo démonstration

    • Performance of 10 cricothyroidotomies in manikins

    Wong D et col; Anesthesiology 2003


    Airway management in the prehospital setting

    Failure of intubation after 2 attempts under direct laryngoscopy

    Success

    New direct laryngoscopy with BURP

    Success

    Use of GEB ( 2 attempts)

    Use of the ILMA and call for help

    Success

    Intubation through the ILMA

    Ventilation through the ILMA

    Success

    Failure

    Transfer to the Hospital with ventilation through the ILMA

    Cricothyroidotomy


    Non invasive positive pressure ventilation

    Non invasive positive pressure ventilation

    • CPAP or BiPAP

    • Validated for COPD decompensation and severe « cardiogenic pulmonary oedema »

    • Majority of the studies are inhospital

    • Potential large indications exist in the prehospital setting


    In practice

    In practice


    Conclusion

    Conclusion

    • In the prehospital setting the gold standard of invasive airway management remains tracheal intubation under direct laryngoscopy

    • Rapid sequence induction should be performed for all patients with spontaneous cardiac activity in absence of contraindications

    • Predefined strategy including simple and effective devices is the best mean to solve difficult airway management situations

    • Non invasive airway control with face mask is feasible in prehospital setting. Further large studies are needed to precise the best indications of prehospital NPPV


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