Emergency Airway Management in Trauma Patients

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Apr 26, 2011 - Suction, Prehospital Emergency Care, 15:3, 347-350. To link to this article: ... is common and associated with a higher mortality, reliable ... and the staff of the Paramedic School of the Frankfurt Fire Depart- ment for their ...
Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Emergency Airway Management in Trauma Patients Using Laryngeal Tube Suction Richard Schalk RN, NREMT-P, Dirk Meininger MD, Miriam Ruesseler MD, Dieter Oberndörfer, Felix Walcher MD, Kai Zacharowski MD, PhD, Leo Latasch MD & Christian Byhahn MD To cite this article: Richard Schalk RN, NREMT-P, Dirk Meininger MD, Miriam Ruesseler MD, Dieter Oberndörfer, Felix Walcher MD, Kai Zacharowski MD, PhD, Leo Latasch MD & Christian Byhahn MD (2011) Emergency Airway Management in Trauma Patients Using Laryngeal Tube Suction, Prehospital Emergency Care, 15:3, 347-350 To link to this article: http://dx.doi.org/10.3109/10903127.2011.561405

Published online: 26 Apr 2011.

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Date: 03 November 2015, At: 03:13

EMERGENCY AIRWAY MANAGEMENT IN TRAUMA PATIENTS USING LARYNGEAL TUBE SUCTION Richard Schalk, RN, NREMT-P, Dirk Meininger, MD, Miriam Ruesseler, MD, ¨ Dieter Oberndorfer, Felix Walcher, MD, Kai Zacharowski, MD, PhD, Leo Latasch, MD, Christian Byhahn, MD

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ABSTRACT

derwent urgent LTS-D removal and subsequent ETI upon hospital admission, six underwent ETI after primary survey, and 26 underwent both primary and secondary survey or even damage-control surgery with the LTS-D. Conclusion. The LTS-D represents a promising alternative to ETI in the hands of both paramedics and emergency physicians. It can be used as an initial tool to secure the airway until ETI is prepared, as a definitive airway by rescuers less experienced in ETI, or as a rescue device when ETI has failed. Key words: trauma; emergency medicine; prehospital; airway; laryngeal tube; emergency room

Background. Endotracheal intubation (ETI) is considered to be the “gold standard” of prehospital airway management of trauma patients. However, ETI requires substantial technical skills and ongoing experience. Because failed prehospital ETI is common and associated with a higher mortality, reliable airway devices are needed to be used by rescuers who are less experienced in ETI. Objective. To prospectively evaluate the feasibility of the use of laryngeal tubes by paramedics and emergency physicians for out-of-hospital airway management in trauma patients. Methods. During a 40-month period, data for all cases of prehospital use of the laryngeal tube suction disposable (LTS-D) within a large metropolitan area were recorded by a standardized questionnaire. We determined indications for laryngeal tube use, placement success, number of placement attempts, placement time, and personal level of experience. All patients admitted to our institution also underwent in-hospital follow-up. Results. Fifty-six of 57 prehospital intubations attempts with the LTSD were successfully performed by paramedics (n = 19) or emergency physicians (n = 37) within one (n = 50) or two (n = 6) placement attempts. The device was used as initial airway (n = 27) or rescue device after failed ETI (n = 30). The placement time was ≤45 seconds (n = 42), 46–90 seconds (n = 13), and >90 seconds (n = 1). The majority of users (n = 44) were relative novices with no more than 10 previous laryngeal tube placements on actual patients. Of 33 patients eligible for follow-up, one un-

PREHOSPITAL EMERGENCY CARE 2011;15:347–350

INTRODUCTION Establishing and maintaining a secure airway is one of the most important technical skills in acute trauma care and the very first stage of the primary survey in Advanced Trauma Life Support (ATLS). Intubating the trachea under direct laryngoscopy with a standard endotracheal tube is the “gold standard” for airway management in trauma patients. However, failed prehospital endotracheal intubation (ETI) is common and associated with a higher mortality. Reliable airway devices are needed to be used by rescuers who are less experienced in ETI. Even experienced emergency physicians encounter initial difficulties to intubate due to a variety of factors, such as nonfasting patients, facial trauma and hemorrhage, and limited or difficult access to the airway due to confined space or entrapment. The 2005 European Resuscitation Council (ERC) guidelines for resuscitation state that tracheal intubation should be attempted only by trained personnel with adequate continuous experience. Rescuers without appropriate experience in ETI should use acceptable alternatives for airway management. Regardless of which alternative device is used, it has to meet the following criteria: It should be easy to handle and should guarantee reliable protection against aspiration.1 The laryngeal tube and its derivative, the laryngeal tube suction, were introduced as an alternative for managing the difficult airway, initially intended for routine clinical use.2 Within recent years, laryngeal tubes have also been reported to be successfully used for out-of-hospital and emergency airway management.3–5 The aim of the study was to prospectively evaluate the feasibility of the use of laryngeal tubes by

Received July 8, 2010, from the Clinic of Anesthesiology, Intensive Care Medicine, and Pain Therapy (RS, DM, KZ, CB), and the Department of Trauma Surgery (MR, FW), J.W. Goethe University Hospital Frankfurt, Frankfurt, Germany; the Municipality of Frankfurt, Fire Department (DO), Frankfurt, Germany; and the Municipality of Frankfurt, Public Health Department (LL), Frankfurt, Germany. Revision received October 7, 2010; accepted for publication October 28, 2010. The authors would like to thank all the paramedics and emergency physicians of the participating emergency medical services systems and the staff of the Paramedic School of the Frankfurt Fire Department for their continuous efforts and support of this study. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence and reprint requests to: Christian Byhahn, MD, Clinic of Anesthesiology, Intensive Care Medicine, and Pain Therapy, J.W. Goethe University Hospital, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany. e-mail: [email protected] doi: 10.3109/10903127.2011.561405

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paramedics and emergency physicians for prehospital trauma care in four operational areas of emergency medical services (EMS) systems in Germany and Switzerland.

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METHODS During a 40-month period, a cohort study was performed, during which data for all prehospital intubations in trauma patients with the laryngeal tube suction disposable (LTS-D, VBM Medizintechnik GmbH, Sulz am Neckar, Germany) performed by paramedics and emergency physicians were recorded by means of a standardized questionnaire, which was approved by the institutional review board. The operational areas of the EMS systems consisted of the German metropolitan area Frankfurt-Rhein Main (City of Frankfurt, districts Main-Taunus and Hochtaunus) and the Swiss canton Appenzell-Innerrhoden. Furthermore, all patients admitted to the emergency department (ED) of the Frankfurt University Hospital underwent inhospital follow-up. All paramedics and emergency physicians underwent a training program in airway management with the LTS-D that consisted of a 45-minute lecture and 45minute hands-on manikin training. Moreover, the participants were invited to use the LTS-D on a voluntary basis in three to five patients during routine anesthetic procedures at the University Hospital Frankfurt.

Data Acquisition Standardized questionnaires were distributed to all EMS operators who participated in the study and returned by mail to the primary investigator immediately after the rescue mission. The questionnaires were made anonymous in terms of both the patient’s and the rescuer’s personal data and the location of the mission. The data recorded comprised demographics, indications for LTS-D placement, placement success, insertion time and attempts required, and personal level of experience with the device.

Statistics After testing for Gaussian distribution, all data were expressed as mean ± standard deviation or number as appropriate. All statistical calculations were performed with IBM-based software packages using Fisher’s exact test (Microsoft Excel 2007, Microsoft Deutschland GmbH, Unterschleißheim, Germany; and GraphPad InStat Version 3.06, GraphPad Software Inc., San Diego, CA, USA).

RESULTS Fifty-six adults (mean age 46 ± 16 years, mean body mass index 27.9 ± 5.6 kg/m2 ) and one child (aged

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TABLE 1. Indications for Emergency Airway Management in 57 Trauma Patients Multiple trauma Isolated head injury Isolated trauma (extremities, thorax, pelvis, etc.) Strangulation or hanging Burns Concomitant cardiac arrest Concomitant maxillofacial trauma

n = 33 n = 13 n=7 n=3 n=1 n = 14 n = 12

Multiple answers were permitted.

7 years) underwent emergency airway management with the LTS-D. Except for the child, who suffered isolated burn injuries, all patients had the cervical spine immobilized with a rigid cervical collar (Stifneck Select, Laerdal, Puchheim, Germany) prior to managing the airway. According to the manufacturer’s instructions for use, the LTS-D sizes used were size 5 (n = 35), size 4 (n = 21), and size 3 (n = 1). The specific indications for airway management are shown in Table 1. Compared with the paramedics, who used the LTS-D almost exclusively as first-line airway, the emergency physicians used it primarily in failed ETI (p < 0.0001). Except in patients who were in cardiac arrest, anesthesia was induced with either propofol, etomidate, or thiopental, and muscle relaxation was achieved with suxamethonium (i.e., succinylcholine). Placement was successful in all but one patient (Table 2). The emergency physician in charge failed to place both the endotracheal tube and the LTS-D in a patient with a shattered larynx who was in cardiac arrest after hanging. Successful LTS-D placement was confirmed by visible chest movements and auscultation. Additional capnography was used in 17 patients who were not in cardiac arrest. Correct gastric drain tube placement was assumed when the drain tube could be advanced properly. No specific gastric auscultation was performed. The time to successful placement of the tube, the number of placement attempts required, and the previous personal level of experience with the device are shown in Table 3. After successful placement, the LTS-D was left in place throughout treatment at the scene and, if applicable, subsequent transport to the hospital in all but two cases, in which it was removed on the scene by the attending emergency physician and replaced by an endotracheal tube. The reason was “personal preference of endotracheal intubation” before helicopter transport in one case, and recurring respiratory distress after initial chest tube drainage in a victim of stabbing assault. However, ETI did not improve the situation, and thoracic computed tomography (CT) scan performed upon arrival in the ED revealed bilateral ventral tension pneumothorax. Six patients died at the scene, and 18 patients were transferred to medical centers other than ours and thus were lost to follow-up, leaving 33 patients who

Schalk et al.

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TABLE 2. Indications for Laryngeal Tube Use and Placement Success

LTS-D used as first-line airway LTS-D used as rescue device after failed endotracheal intubation LTS-D placement successful

Total (n = 57)

Paramedics (n = 19)

Emergency Physicians (n = 38)

27 (47.4%) 30 (52.6%)

17 (89.5%)∗ 2 (10.5%)∗

10 (26.3%) 28 (73.7%)

56 (98.2%)

19 (100%)

37 (97.4%)

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Data are number (%). ∗ p < 0.0001 versus emergency physicians. LTS-D = laryngeal tube suction disposable.

were admitted to the Frankfurt University Hospital. During the primary survey in the ED, one patient with severe head and facial trauma required urgent removal of the LTS-D and subsequent ETI because of insufficient ventilation via the LTS-D. Six patients underwent ETI after the primary survey because the proximal cuff of the LTS-D interfered with posterior nasal balloon tamponade placement and/or intraoral and pharyngeal hemostasis. In 23 patients, both primary and secondary survey, consisting of chest and pelvic x-ray examination and a whole-body CT scan, was performed with the laryngeal tube in place. After initial stabilization, these patients underwent definitive airway management by elective ETI. In the remaining patients (n = 3), emergency surgery (i.e., damage-control laparotomy, decompressive craniectomy, and pelvic stabilization) was performed under sufficient ventilation via the LTS-D. Thereafter, patients underwent either ETI using the same technique as described above (n = 2) or surgical tracheostomy (n = 1).

DISCUSSION The results of our study show that the LTS-D was effective in the hands of both paramedics and emergency physicians in managing the airways of trauma patients in out-of-hospital environments and maintaining them during initial survey in the ED and even during subsequent damage-control surgery. In 88% of the cases, the laryngeal tube could be placed within the first attempt, and all but one airway were managed within

TABLE 3. Time until Successful Placement of the Laryngeal Tube, Number of Placement Attempts, and Previous Personal Experience with Laryngeal Tube Placement Insertion Time 46–90 sec >90 sec 13 (22.7%) 1 (1.8%)

≤45 sec 42 (73.7%) 1 50 (87.7%) ≤5 34 (59.6 %)

Failed Placement 1 (1.8%)

Number of Placement Attempts 2 3 Failed Placement 6 (10.5%) 0 1 (1.8%) Previously Placed Laryngeal Tubes (n) 6–10 >10 Not Specified 10 (17.5%) 12 (21.1%) 1 (1.8%)

Data are number (%).

two attempts. Insertion of the LTS-D was entirely impossible in a patient with severe laryngeal trauma and cardiac arrest in whom various intubation attempts had failed, as did a subsequent cricothyrotomy attempt. The standard measures of prehospital airway management, bag–valve–mask ventilation and ETI, both require a skilled rescuer and ongoing training and experience. Previous studies have questioned the usefulness of prehospital ETI by relatively inexperienced rescuers, regardless of paramedics or emergency physicians.6–10 A recent survey of ETIs performed by paramedics in trauma patients revealed a rate of failed intubations of 31%, including unrecognized esophageal tube placement in 12% of the entire cohort.6 Figures from physician-based EMS systems in Germany are not much different, showing an 11% rate of unrecognized endobronchial intubations and a 7% rate of unrecognized esophageal intubations.8 Considering that an average laryngoscopist needs at least 57 elective ETIs under optimal conditions to reach a 90% success rate at the first intubation attempt,11 reliable airway management alternatives for rescuers less experienced in ETI are urgently required. Supraglottic airway devices, such as laryngeal masks and laryngeal tubes, seem to be quite appropriate for emergency airway management in the field. Both devices have a high placement success rate within a short time even in the hands of novices and less experienced users, and even after a short training, skill retention is high.12–14 Forty-four of 57 of the rescuers in our study had performed no more than 10 laryngeal tube applications in clinical routine and under supervision before using the device in the field, on their own and under emergency conditions. The fact that the majority of users were relative novices, and that establishing an airway with the LTS-D required less than 45 seconds in most of the cases, underlines the value of this device as an alternative airway when ETI has failed, is considered difficult, or needs to be performed by an inexperienced rescuer. Laryngeal tubes actively seal the upper esophagus with their distal cuff, thus providing a better airway seal than laryngeal masks,15 which is an important advantage especially during cardiopulmonary resuscitation when higher inspiratory pressures must be generated. The effect of the esophageal seal and the

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gastric drain tube on the incidence of regurgitation may be advantageous, although this has not yet been formally studied. We did not perform gastric auscultation after LTSD placement. However, it could be demonstrated in one study that tracheal misplacement of the LTS-II occurred in five of 50 anesthetized and paralyzed patients.16 Even though ventilation was still possible in four of them and tracheal misplacement was only revealed by fluoroscopy, the study suggests that additional gastric auscultation after LTS-II placement provides a wider margin of safety than chest auscultation alone. While in the majority of patients both primary and secondary survey according to the ATLS algorithm could be performed under controlled ventilation via the LTS-D, urgent removal of the LTS-D and subsequent ETI were required immediately upon arrival of one patient in the ED. Retrospectively, the reason for a sudden, excessive increase of inspiratory pressure was torsion of the LTS-D around its longitudinal axis, resulting in obstruction of the airway passages. When we encountered the phenomenon of sudden rise in ventilation pressure later during the course of this study, readjustment of the LTS-D solved the problem instantly in all cases. It is indeed a fact that the proximal cuff of the LTS-D may herniate, thereby obstructing the ventilation orifices/airway passage. If such difficulties occur, the cuffs should be slightly deflated until ventilation can be reestablished.

LIMITATIONS Data regarding the time to LTS-D placement and the number of placement attempts required were not recorded by an objective observer, but by the users and by means of a questionnaire. Thus, such data are subjective and could be potentially biased.

CONCLUSION Based on our study, we were able to demonstrate that the LTS-D represents a promising alternative to ETI in the hands of both paramedics and emergency physicians. It can be used as an initial tool to secure the airway until ETI is prepared, as a definitive airway by rescuers less experienced with ETI, or as a rescue device when ETI has failed.

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