EMS World

JAN 2019

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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EMSWORLD.com | JANUARY 2019 21 M rs. Smith is a 68-year-old wife, mother, and grandmother. She has been feeling "punky" for a few days—nothing specific, just not quite right. Today she starts to get a bit short of breath. Because of her history of medical prob- lems, this isn't unusual for Mrs. Smith. She takes her albuterol inhaler and continues to take her daily furosemide as prescribed. Unfortunately her breathing gets worse, eventually becoming bad enough that she calls 9-1-1. A medic unit and field supervisor respond to her home. They find her sitting upright in her living room in obvious respiratory distress. She is sweaty and anxious. They begin their assessment and find her to be tachycardic, mildly hypertensive, and afe- brile, with a saturation of 90%. They apply a nonrebreather mask while assessing breath sounds. Hearing expiratory wheez- es, they administer nebulized albuterol and ipratropium. Her pulse oximetry does not improve. In fact, it begins falling. Realizing the nebulizer alone isn't work- ing, they place her on CPAP. Unfortunately Mrs. Smith is becoming agitated and con- fused. She starts trying to push the CPAP mask off her face. She isn't tolerating their attempts to help her. After a brief discus- sion the crew collectively decides she has failed noninvasive ventilation and proceeds to intubation with rapid-sequence induc- tion (RSI). They push 2 mg/kg of IV ket- amine, rapidly followed by 2 mg/kg of IV succinylcholine. As Mrs. Smith relaxes and becomes apneic, they lower her to a supine position on the ground. Medics begin to intubate her using a video laryngoscope. Everyone watches the display as what was antici- pated to be an easy intubation becomes difficult. Nobody, however, is watching the monitor. 86%. 80%. 75%. 60%. Mrs. Smith, who had an initial heart rate of 120, is becoming bradycardic. Her rate drops faster and faster. 80. 50. 30. Zero. Mrs. Smith is now in asystole. Recog- nizing this, medics abort the intubation attempt, begin compressions, and venti- late with a BVM. Her saturation improves to 90%, and they get pulses back. A sec- ond paramedic attempts intubation and is successful. Her saturations rise to 96%, and her pulse and blood pressure stabilize. Whew! The medics tell themselves Mrs. Smith is very sick, and sometimes these things just happen. "Nothing we could have done differently." Fortunately all is well now, so no harm, no foul. However, Mrs. Smith never wakes up. She has permanent hypoxic brain injury and remains in a vegetative state. Her husband, children, and grandchildren won't get her back. All because of an unforeseeable and inevitable illness. But was it really unforeseeable? Was it really inevitable? Mrs. Smith suffered a peri-intubation hypoxic cardiac arrest—a rapid-sequence death. This is not only predictable but pre- ventable. By systematically changing the way we approach intubation, we can pre- vent this and assure that future Mrs. Smiths get to go home to their families. Peri-Intubation Hypoxia Intubation has been a part of paramedic training since the first national curriculum. Training materials have always mentioned some variety of the P's of intubation: prepa- ration, preoxygenation, pretreatment, and paralysis. Unfortunately most of these P's have been glossed over in both training and practice. Many medics (and physicians) skip straight to the "sexy" step of insert- ing the endotracheal tube. This disregard for the fundamentals has made peri-intu- bation hypoxia common in both EMS and the hospital. In a 2003 study of EMS RSI in patients with traumatic brain injuries, 57% of patients had at least one hypoxic episode during intubation. 1 The majority of these (81%) were not hypoxic to begin with and were felt by the intubating medics to be "easy tubes." Nine percent of these patients also experienced bradycardia. More recently a team led by investigators from Physio-Control found 43% of patients undergoing EMS RSI experienced peri-intu- bation hypoxia; 68% were severe (SpO 2 less than 80%). 2 The median attempt nadir (lowest saturation) was 71%, and the 25th percentile was a shocking 36%. This means a quarter of all intubations had saturations during intubation of less than 36%! These were not brief episodes; the median dura- tion was two minutes. This was also in a system with an above-average first-pass success rate (FPS) of 82%. In fact, 70% of all desaturations occurred on first pass. Clearly FPS alone is not sufficient to pre- vent hypoxia. This doesn't just occur in the field. Of 166 emergency department RSI intuba- tions, 36% experienced a peri-intubation hypoxic episode. Of these, 93% were not hypoxic to begin with. 3 This isn't a function of bad paramedics or physicians. As humans, we are prone to becoming task-saturated during critical events, such as intubating a sick patient (and we don't exactly intubate nonsick patients). Of 100 directly obser ved ED intubations, physicians underestimated both how many patients had desaturation (23% observed vs. 13% perceived) and how long the intubation attempt took (45 sec- onds vs. 23 seconds). 4 This is a function of being human, not a bad provider. We are not able to reliably intubate and monitor patients during an emergency. We need to systematically change how we intubate to avoid this. Peri-intubation hypoxia is not only common, it is also harmful, particularly in patients with conditions that do not toler- ate hypoxia and tissue ischemia well—trau- matic brain injury, for example. The odds ratio for death in these patients with one episode of hypoxia in a prehospital study was 3.9. 5 This means the odds of death were 290% higher for patients with hypoxia than those without. This wasn't an isolated finding; in a large state registry of TBI patients, the odds ratio of death in patients with hypoxia was even higher, 6.6. 6 This study also looked at the effects of hypotension and found that a single episode of hypotension was associ- ated with 340% higher odds of death and, shockingly, the odds of death in patients with both hypotension and hypoxia were 1,220% (OR 13.2) higher than for patients who had neither. Hypoxia is also associated with hemo- dynamically significant bradycardia and tion (RSI). They push 2 mg/kg of IV ket- amine, rapidly followed by 2 mg/kg of IV succinylcholine.

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