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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26 JANUARY 2019 | EMSWORLD.com COVER REPORT: AIRWAY MANAGEMENT oxygenation was associated with 34% lower odds of peri-intubation hypoxia. 28 Delayed-sequence intubation (DSI) is the process of giving ketamine followed by a delay in inducing paralysis to allow for better preoxygenation. DSI improved the SpO 2 from 89% after maximal efforts at preoxygenation to 98% in ICU patients 29 and has been safely implemented in EMS. 30 Implementing It in Texas After experiencing a sentinel event with a critical patient involving peri-intubation hypoxia, Texas' Williamson County EMS undertook a continuous quality improve- ment project aimed at changing the envi- ronment, culture, and processes around intubating nonarrest patients. The aim of the project was to prevent peri-intubation hypoxia. First we went back and looked at our data to make sure our critical event wasn't isolated. It was not. In fact, 44% of our RSIs had a peri-intubation hypoxic event, and we found two additional cases of peri- intubation cardiac arrest, putting us in line with existing literature on the frequency of these occurrences. 31 We implemented a bundle of care that consisted of a mandatory checklist-driven protocol that included proper positioning, goal-directed preox ygenation, apneic ox ygenation, and DSI for all patients. Positioning required the head of the bed to be elevated at least 15 degrees and the patient placed in an E2SN position. Goal-directed preoxygenation required the use of a BVM with PEEP and reservoir with flush-rate oxygen held in a two-per- son, two-thumbs-down seal, achieving a SpO 2 of greater than 93% for at least three minutes. Nasal cannulas were placed and increased to flush rate after sedation. DSI was performed with ketamine and rocuronium on all patients. If we could not achieve our goal saturation, intubation was not allowed under any circumstances. If the patient needed airway protection and could not achieve this goal, an i-gel could be placed. We published the results earlier this year, comparing 104 intubations performed before implementing this bundle to 87 done after. 32 Patient characteristics of the two groups were the same. The primary outcome of the study was the proportion of patients who experienced peri-intu- bation hypoxia. This rate decreased from 44.2% to 3.5% after implementing the bundle. The 25th-percentile peri-intuba- tion nadir increased from 73.8% to 96%, and the rate of bradycardia decreased from 18.3% to 2.3%. We graphically rep- resented the change in the SpO 2 at the beginning of the intubation attempt (after maximal preoxygenation efforts) and the SpO 2 nadir in Figure 4. A Call to Action Our experience clearly demonstrates that paying attention to the details of intuba- tion, particularly achieving adequate pre- oxygenation, proper patient positioning, apneic oxygenation, goal-directed oxygen saturations, and using delayed sequence intubation, can decrease peri-intubation hypoxia. This isn't the only way to achieve this goal, but it worked well for us and can work for others. If all agencies adopt this or a similar approach, we can collectively ensure there are no more cases like Mrs. Smith's. Help make intubation safer by avoiding peri- intubation hypoxia. REFERENCES References are available at www.emsworld.com/ article/1221763. ABOUT THE AUTHOR Jeffrey L. Jarvis, MD, MS, EMT-P, FACEP, FAEMS, is EMS medical director for the Williamson County EMS system and Marble Falls Area EMS and an emergency physician at Baylor Scott & White Hospital in Round Rock, Tex. He is board-certified in emergency medicine and EMS. He began his career as a paramedic with Williamson County EMS in 1988 and continues to maintain his paramedic license. Figure 4. Waterfall plot of SPO 2 change. (Infographic: Jeff rey Jarvis)

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