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Evaluation of Airway Management Proficiency in Pre-Hospital Emergency Setting; a Simulation Study

Shahrzad Ghiyasvandian, Afshin Khazaei, Masoumeh Zakerimoghadam, Rasoul Salimi, Ali Afshari, Abbas Mogimbeigi
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Abstract

Introduction: Infrequency and low exposure to critically ill patients requiring airway management will lead to reduction in the skills and performance of the Emergency Medical Technicians (EMTs) over time. The present study was conducted primarily aiming to evaluate airway management in stationary ambulance simulations and identify the factors affecting Endotracheal Intubation (ETI) success rate.

Method: This is a simulation study. The study population comprised of active EMTs in prehospital emergency bases in Hamadan province. The participants were placed at the back of an ambulance to perform the airway management scenario, which had already been prepared. To investigate the factors affecting the success (≤3 attempts) or failure rate of intubation, both unadjusted and adjusted odds ratios (95% confidence intervals) for univariate and multivariate regressions were reported.

Results: 184 subjects with the mean age of 33.91+6.25 years and the median work experience of 8 years were studied (54.3% with a history of training in the past year).  The median number of previous intubations performed by technicians in the last year was 7 times (IQR 4-9). The total success rate at ventilation, intubation and back-up airway were 50.67%, 53.29%, and 50.0%, respectively. Out of the total 552 attempts for ETI placement, 58.2% of the technicians were able to perform ETI within 3 attempts. Univariate analysis showed that age (OR=1.06, P=0.022), previous number of ETIs (OR=2.49, P<0.001), work experience (OR=1.13, P<0.001), and previous ETI training (OR=1.85, P=0.041) were significantly associated with ETI success rate. After adjustment, previous number of ETIs (OR=2.66, P<0.001) was the most effective factor on ETI success rate.

Conclusion: Success rate in airway management, especially ETI, is low. Therefore, improvement in modifiable factors such as increasing the number of ETIs performed and gaining experience in the same conditions as pre-hospital emergency is necessary.


Keywords

Airway Management; Endotracheal Intubation; Emergency Medicine Technicians

References

Prekker, M.E., H. Kwok, J. Shin, D. Carlbom, A. Grabinsky, and T.D. Rea, The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation. Critical care medicine, 2014. 42(6): p. 1372-1378.

Byars, D., B. Lo, and J. Yates, Evaluation of paramedic utilization of the intubating laryngeal mask airway in high-fidelity simulated critical care scenarios. Prehosp Disaster Med, 2013. 28(6): p. 630-1.

Frerk, C., V.S. Mitchell, A.F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E.P. O'Sullivan, N.M. Woodall, and I. Ahmad, Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults(). BJA: British Journal of Anaesthesia, 2015. 115(6): p. 827-848.

Cook, T.M., N. Woodall, and C. Frerk, Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth, 2011. 106(5): p. 617-31.

Ahmed, A., F.A. Khan, and S. Ismail, Reliability and validity of a tool to assess airway management skills in anesthesia trainees. Journal of Anaesthesiology, Clinical Pharmacology, 2016. 32(3): p. 333-338.

Thomas, J.B., B.N. Abo, and H.E. Wang, Paramedic perceptions of challenges in out-of-hospital endotracheal intubation. Prehosp Emerg Care, 2007. 11(2): p. 219-23.

Lammers, R.L., M.J. Byrwa, W.D. Fales, and R.A. Hale, Simulation-based assessment of paramedic pediatric resuscitation skills. Prehosp Emerg Care, 2009. 13(3): p. 345-56.

Soar, J., J.P. Nolan, B.W. Bottiger, G.D. Perkins, C. Lott, P. Carli, T. Pellis, C. Sandroni, M.B. Skrifvars, G.B. Smith, K. Sunde, and C.D. Deakin, European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation, 2015. 95: p. 100-47.

Wang, H.E., N.C. Mann, G. Mears, K. Jacobson, and D.M. Yealy, Out-of-hospital airway management in the United States. Resuscitation, 2011. 82(4): p. 378-85.

Diggs, L.A., J.E. Yusuf, and G. De Leo, An update on out-of-hospital airway management practices in the United States. Resuscitation, 2014. 85(7): p. 885-92.

Komasawa, N. and B.W. Berg, Simulation-based Airway Management Training for Anesthesiologists - A Brief Review of its Essential Role in Skills Training for Clinical Competency. J Educ Perioper Med, 2017. 19(4): p. 1-4.

Way, D.P., A.R. Panchal, G.I. Finnegan, and T.E. Terndrup, Airway Management Proficiency Checklist for Assessing Paramedic Performance. Prehosp Emerg Care, 2017. 21(3): p. 354-361.

Maneesriwongul, W. and J.K. Dixon, Instrument translation process: a methods review. J Adv Nurs, 2004. 48(2): p. 175-86.

Park, L., I. Zeng, and A. Brainard, Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Emerg Med Australas, 2017. 29(1): p. 40-47.

Choi, H.J., S.M. Je, J.H. Kim, and E. Kim, The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study. Resuscitation, 2012. 83(11): p. 1363-8.

Kim, C., H.G. Kang, T.H. Lim, B.Y. Choi, Y.J. Shin, and H.J. Choi, What factors affect the success rate of the first attempt at endotracheal intubation in emergency departments? Emerg Med J, 2013. 30(11): p. 888-92.

Hardcastle, T.C., M. Faurie, and D.J.J. Muckart, Endotracheal tube cuff pressures and tube position in critically injured patients on arrival at a referral centre: Avoidable harm? African Journal of Emergency Medicine, 2016. 6(1): p. 24-29.

Ali, M.S., M.H. Bakri, H.A. Mohamed, H. Shehab, and W. Al Taher, External laryngeal manipulation done by the laryngoscopist makes the best laryngeal view for intubation. Saudi Journal of Anaesthesia, 2014. 8(3): p. 351-354.

Panchal, A.R., G. Finnegan, D.P. Way, and T. Terndrup, Assessment of Paramedic Performance on Difficult Airway Simulation. Prehosp Emerg Care, 2016: p. 1-10.

Griesdale, D.E., T.L. Bosma, T. Kurth, G. Isac, and D.R. Chittock, Complications of endotracheal intubation in the critically ill. Intensive Care Med, 2008. 34(10): p. 1835-42.

Mort, T.C., Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg, 2004. 99(2): p. 607-13, table of contents.

Wang, C.H., W.J. Chen, W.T. Chang, M.S. Tsai, P.H. Yu, Y.W. Wu, and C.H. Huang, The association between timing of tracheal intubation and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study. Resuscitation, 2016. 105: p. 59-65.

Kangelaris, K.N., L.B. Ware, C.Y. Wang, D.R. Janz, Z. Hanjing, M.A. Matthay, and C.S. Calfee, Timing of Intubation and Clinical outcomes in Adults with ARDS. Critical care medicine, 2016. 44(1): p. 120-129.

Varshney, M., K. Sharma, R. Kumar, and P.G. Varshney, Appropriate depth of placement of oral endotracheal tube and its possible determinants in Indian adult patients. Indian Journal of Anaesthesia, 2011. 55(5): p. 488-493.

Miller, K.A., A. Kimia, M.C. Monuteaux, and J. Nagler, Factors Associated with Misplaced Endotracheal Tubes During Intubation in Pediatric Patients. J Emerg Med, 2016. 51(1): p. 9-18.

Bucher, J.T. and J.S. Cooper, Bag Mask Ventilation (Bag Valve Mask, BVM), in StatPearls. 2018, StatPearls Publishing

StatPearls Publishing LLC.: Treasure Island (FL).

Soleimanpour, M., F. Rahmani, A. Ala, H.R. Morteza Bagi, A. Mahmoodpoor, S.E.J. Golzari, F. Zahmatyar, R. Mehdizadeh Esfanjani, and H. Soleimanpour, Comparison of four techniques on facility of two-hand Bag-valve-mask (BVM) ventilation: E-C, Thenar Eminence, Thenar Eminence (Dominant hand)-E-C (non-dominant hand) and Thenar Eminence (non-dominant hand) – E-C (dominant hand). Journal of Cardiovascular and Thoracic Research, 2016. 8(4): p. 147-151.

Siegler, J., M. Kroll, S. Wojcik, and H.P. Moy, Can EMS Providers Provide Appropriate Tidal Volumes in a Simulated Adult-sized Patient with a Pediatric-sized Bag-Valve-Mask? Prehosp Emerg Care, 2017. 21(1): p. 74-78.

Mahmoodpoor, A., H. Soleimanpour, K.S. Nia, J.R. Panahi, M. Afhami, S.E.J. Golzari, and K. Majani, Sensitivity of Palm Print, Modified Mallampati Score and 3-3-2 Rule in Prediction of Difficult Intubation. International Journal of Preventive Medicine, 2013. 4(9): p. 1063-1069.

Hansen, M.L., A. Lin, C. Eriksson, M. Daya, B. McNally, R. Fu, D. Yanez, D. Zive, and C. Newgard, A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation, 2017. 120: p. 51-56.

Costello, J.T., P.B. Allen, and R. Levesque, A Comparison of Ventilation Rates Between a Standard Bag-Valve-Mask and a New Design in a Prehospital Setting During Training Simulations. J Spec Oper Med. 17(3): p. 59-63.

Bosch, J., J. de Nooij, M. de Visser, S.C. Cannegieter, N.J. Terpstra, C. Heringhaus, and J. Burggraaf, Prehospital use in emergency patients of a laryngeal mask airway by ambulance paramedics is a safe and effective alternative for endotracheal intubation. Emergency Medicine Journal : EMJ, 2014. 31(9): p. 750-753.

Grmec, S. and S. Mally, Prehospital determination of tracheal tube placement in severe head injury. Emergency Medicine Journal : EMJ, 2004. 21(4): p. 518-520.

Silvestri, S., G.A. Ralls, B. Krauss, J. Thundiyil, S.G. Rothrock, A. Senn, E. Carter, and J. Falk, The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med, 2005. 45(5): p. 497-503.

Neumar, R.W., M. Shuster, C.W. Callaway, L.M. Gent, D.L. Atkins, F. Bhanji, S.C. Brooks, A.R. de Caen, M.W. Donnino, J.M. Ferrer, M.E. Kleinman, S.L. Kronick, E.J. Lavonas, M.S. Link, M.E. Mancini, L.J. Morrison, R.E. O'Connor, R.A. Samson, S.M. Schexnayder, E.M. Singletary, E.H. Sinz, A.H. Travers, M.H. Wyckoff, and M.F. Hazinski, Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2015. 132(18 Suppl 2): p. S315-67.

Saeedi, M., H. Hajiseyedjavadi, J. Seyedhosseini, V. Eslami, and H. Sheikhmotaharvahedi, Comparison of endotracheal intubation, combitube, and laryngeal mask airway between inexperienced and experienced emergency medical staff: A manikin study. International Journal of Critical Illness and Injury Science, 2014. 4(4): p. 303-308.

Kapoor, S., D.D. Jethava, P. Gupta, D. Jethava, and A. Kumar, Comparison of supraglottic devices i-gel(®) and LMA Fastrach(®) as conduit for endotracheal intubation. Indian Journal of Anaesthesia, 2014. 58(4): p. 397-402.

Konrad, C., G. Schupfer, M. Wietlisbach, and H. Gerber, Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg, 1998. 86(3): p. 635-9.

Schupfer, G.K., C. Konrad, and J.I. Poelaert, [Manual skills in anaesthesiology]. Anaesthesist, 2003. 52(6): p. 527-34.

Burton, J.H., M.R. Baumann, T. Maoz, J.R. Bradshaw, and J.E. Lebrun, Endotracheal intubation in a rural EMS state: procedure utilization and impact of skills maintenance guidelines. Prehosp Emerg Care, 2003. 7(3): p. 352-6.




DOI: https://doi.org/10.22037/emergency.v6i1.21973

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