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      Emergency intubation in trauma in KwaZulu-Natal Province, South Africa

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          Abstract

          BACKGROUND: Advanced airway management is a research priority in prehospital care. There is a high burden of major trauma in KwaZulu-Natal (KZN) Province, South Africa (SA), and transfer times to trauma units are often prolonged OBJECTIVES: To examine emergency intubation practice in trauma and burns patients in Pietermaritzburg, KZN, and its environs METHODS: This was a prospective consecutive case series, conducted from 11 May to 17 July 2016. Data were collected from urban emergency department (ED), rural hospital and roadside procedures in Pietermaritzburg and its drainage area. Patients with emergency intubation following trauma were eligible for inclusion. The primary outcome was successful airway management. Secondary outcomes included first-pass success and adverse events. RESULTS: Forty-one cases were recorded in patients aged 1 - 60 years. No instances of unsuccessful airway management were reported. Recorded first-pass intubation success rates were higher in receiving EDs than rural hospitals (19/22 v. 2/7; p=0.003). Use of a formal preintubation checklist was associated with a higher first-pass success rate (21/23 v. 6/15; p=0.001) and fewer adverse events (0/23 v. 7/16; p<0.001). Identified adverse event rates were 1/22 (EDs), 5/8 (rural hospitals) and 2/9 (roadside). Unmedicated intubation was more common in rural hospitals than EDs (3/8 v. 1/22; p=0.019), despite absence of cardiac arrest in these cases. Minimum standards of anaesthetic monitoring were not consistently met in any setting CONCLUSIONS: The use of a preprocedural checklist was associated with improved intubation outcomes and may improve practice in SA trauma care and the prehospital environment, including in rural hospitals. Standardised rapid sequence induction protocols, routine use of introducers and end-tidal carbon dioxide monitoring, and increased availability of intraosseous devices also merit consideration. Key performance indicators should be monitored routinely

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          Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.

          Both the American Society of Anesthesiologists and the UK NAP4 project recommend that an unspecified pre-operative airway assessment be made. However, the choice of assessment is ultimately at the discretion of the individual anaesthesiologist. We retrieved a cohort of 188 064 cases from the Danish Anaesthesia Database, and investigated the diagnostic accuracy of the anaesthesiologists' predictions of difficult tracheal intubation and difficult mask ventilation. Of 3391 difficult intubations, 3154 (93%) were unanticipated. When difficult intubation was anticipated, 229 of 929 (25%) had an actual difficult intubation. Likewise, difficult mask ventilation was unanticipated in 808 of 857 (94%) cases, and when anticipated (218 cases), difficult mask ventilation actually occurred in 49 (22%) cases. We present a previously unpublished estimate of the accuracy of anaesthesiologists' prediction of airway management difficulties in daily routine practice. Prediction of airway difficulties remains a challenging task, and our results underline the importance of being constantly prepared for unexpected difficulties.
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            Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

            Introduction Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety. Methods We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene. Results From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047). Conclusions This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.
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              The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration

              Background Physician-manned emergency medical teams supplement other emergency medical services in some countries. These teams are often selectively deployed to patients who are considered likely to require critical care treatment in the pre-hospital phase. The evidence base for guidelines for pre-hospital triage and immediate medical care is often poor. We used a recognised consensus methodology to define key priority areas for research within the subfield of physician-provided pre-hospital critical care. Methods A European expert panel participated in a consensus process based upon a four-stage modified nominal group technique that included a consensus meeting. Results The expert panel concluded that the five most important areas for further research in the field of physician-based pre-hospital critical care were the following: Appropriate staffing and training in pre-hospital critical care and the effect on outcomes, advanced airway management in pre-hospital care, definition of time windows for key critical interventions which are indicated in the pre-hospital phase of care, the role of pre-hospital ultrasound and dispatch criteria for pre-hospital critical care services. Conclusion A modified nominal group technique was successfully used by a European expert group to reach consensus on the most important research priorities in physician-provided pre-hospital critical care.
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                Author and article information

                Affiliations
                Pietermaritzburg orgnameNetcare 911 South Africa
                Birmingham orgnameSurgical Reconstruction and Microbiology Research Centre orgdiv1National Institute for Health Research UK
                Pietermaritzburg orgnameEdendale Hospital South Africa
                orgnameRaigmore Hospital UK
                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                samj
                SAMJ: South African Medical Journal
                SAMJ, S. Afr. med. j.
                Health and Medical Publishing Group (Cape Town, Western Cape Province, South Africa )
                0256-9574
                2078-5135
                August 2018
                : 108
                : 8
                : 660-666
                S0256-95742018000800017
                10.7196/samj.2018.v108i8.12670

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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                Figures: 0, Tables: 0, Equations: 0, References: 22, Pages: 7
                Product
                Product Information: SciELO South Africa

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