Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Else Tønnesen³  Hans Kirkegaard²  Troels Martin Hansen¹  Leif Rognås¹ 

[1] Department of Pre-hospital Medical Services, Central Denmark Region, Oluf Palmes Allé 34, 8200 Aarhus N, Denmark;Centre for Emergency Medicine Research, Aarhus University Hospital, Trøjborgvej 72-74, Building 30, 8200 Aarhus N, Denmark;Department of Anaesthesiology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, Denmark

关键词: Critical decision making (MeSH);    Patient safety;    Endotracheal intubation (MeSH);    Airway management (MeSH);    Critical care (MeSH);    Helicopter emergency medical service;    Emergency medical services (MeSH);    Prehospital emergency care (MeSH);    Out-of-hospital;    Pre-hospital;   

Others  :  821145
DOI  :  10.1186/1757-7241-21-75

 received in 2013-08-10, accepted in 2013-10-17,  发布年份 2013

【 摘 要 】

Introduction

We report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions.

Materials and methods

Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) registered data from February 1^st 2011 to October 31^st 2012. Included were patients of all ages for whom pre-hospital advanced airway management were considered but not performed. The main objectives were to investigate (1) the pre-hospital critical care anaesthesiologists’ reasons for considering performing pre-hospital advanced airway management in this group of patients (2) the pre-hospital critical care anaesthesiologists’ reasons for not performing pre-hospital advanced airway management (3) the methods used to treat these patients (4) the incidence of complications related to pre-hospital advanced airway management not being performed.

Results

We registered data from 1081 cases in which the pre-hospital critical care anaesthesiologists’ considered performing pre-hospital advanced airway management. The anaesthesiologists decided to withhold pre-hospital advanced airway management in 32.1% of these cases (n = 347). In 75.1% of these cases (n = 257) pre-hospital advanced airway management were withheld because of the patient’s condition and in 30.8% (n = 107) because of patient co-morbidity. The most frequently used alternative treatment was bag-mask ventilation, used in 82.7% of the cases (n = 287). Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2).

Conclusion

We have illustrated the complexity of the critical decision-making associated with pre-hospital advanced airway management. This study is the first to identify the most common reasons why pre-hospital critical care anaesthesiologists sometimes choose to abstain from pre-hospital advanced airway management as well as the alternative treatment methods used.

【 授权许可】

   
2013 Rognås et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Fevang E, Lockey D, Thompson J, Lossius HM: The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration. Scand J Trauma, Resusc Emerg Med 2011, 19:57. BioMed Central Full Text
• [2]Sollid SJ, Lockey D, Lossius HM: A consensus-based template for uniform reporting of data from pre-hospital advanced airway management. Scand J Trauma, Resusc Emerg Med 2009, 17:58. BioMed Central Full Text
• [3]Adnet F, Jouriles NJ, Le Toumelin P, Hennequin B, Taillandier C, Rayeh F, Couvreur J, Nougiere B, Nadiras P, Ladka A, et al.: Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study. Ann Emerg Med 1998, 32(4):454-460.
• [4]Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arntz HR, Mochmann HC: Expertise in prehospital endotracheal intubation by emergency medicine physicians-Comparing 'proficient performers’ and 'experts’. Resuscitation 2012, 83(4):434-439.
• [5]Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann HC, Arntz HR: Difficult prehospital endotracheal intubation - predisposing factors in a physician based EMS. Resuscitation 2011, 82(12):1519-1524.
• [6]Chesters A, Keefe N, Mauger J, Lockey D: Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emergency medicine journal : EMJ 2013, 2013:2013.
• [7]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 : EMJ 2011, 28(3):225-229.
• [8]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 (London, England) 2012, 16(1):R24. BioMed Central Full Text
• [9]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, 21(1):58. BioMed Central Full Text
• [10]Timmermann A, Eich C, Russo SG, Natge U, Brauer A, Rosenblatt WH, Braun U: Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians. Resuscitation 2006, 70(2):179-185.
• [11]Von Vopelius-Feldt J, Benger JR: Prehospital anaesthesia by a physician and paramedic critical care team in Southwest England. Eur J Emerg Med 2012., 00No 00. DOI: 10.1097/MEJ.0b013e32835b08b7
• [12]Wang HE, O’Connor RE, Domeier RM: Prehospital rapid-sequence intubation. Prehosp Emerg Care 2001, 5(1):40-48.
• [13]Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, et al.: Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg 2010, 252(6):959-965.
• [14]Franschman G, Peerdeman SM, Greuters S, Vieveen J, Brinkman AC, Christiaans HM, Toor EJ, Jukema GN, Loer SA, Boer C: Prehospital endotracheal intubation in patients with severe traumatic brain injury: guidelines versus reality. Resuscitation 2009, 80(10):1147-1151.
• [15]Sollid SJ, Lossius HM, Soreide E: Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service. Scand J Trauma, Resusc Emerg Med 2010, 18:30. BioMed Central Full Text
• [16]Helm M, Kremers G, Lampl L, Hossfeld B: Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists. Acta Anaesthesiol Scand 2013, 57(2):199-205.
• [17]Perkins ZB, Gunning M, Crilly J, Lockey D, O’Brien B: The haemodynamic response to pre-hospital RSI in injured patients. Injury 2013, 44(5):618-623.
• [18]Perkins ZB, Wittenberg MD, Nevin D, Lockey DJ, O’Brien B: The relationship between head injury severity and hemodynamic response to tracheal intubation. J Trauma Acute Care Surg 2013, 74(4):1074-1080.
• [19]Rognas LK, Hansen TM: EMS-physicians’ self reported airway management training and expertise; a descriptive study from the Central Region of Denmark. Scand J Trauma, Resusc Emerg Med 2011, 19:10. BioMed Central Full Text
• [20]Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, et al.: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013, 118(2):251-270.
• [21]Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Bottiger B: European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010, 81(10):1219-1276.
• [22]Bosse G, Schmidbauer W, Spies CD, Sorensen M, Francis RC, Bubser F, Krebs M, Kerner T: Adherence to guideline-based standard operating procedures in pre-hospital emergency patients with chronic obstructive pulmonary disease. J Int Med Res 2011, 39(1):267-276.