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Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation.

ABSTRACT: Airway and breathing management play critical role in trauma resuscitation. Early identification of esophageal intubation and detection of fatal events is critical. Authors studied the utility of integration of point-of-care ultrasound (POCUS) during different phases of rapid sequence intubation (RSI) in trauma resuscitation.It was prospective, randomized single-centered study conducted at the Emergency Department of a level one trauma center. Patients were divided into ultrasonography (USG) and clinical examination (CE) arm. The objectives were to study the utility of POCUS in endotracheal tube placement and confirmations and identification of potentially fatal conditions as tracheal injury, midline vessels, paratracheal hematoma, vocal cord pathology, pneumothorax, and others during RSI. Patient >1 year of age were included. Time taken for procedure, number of incorrect intubations, and pathologies detected were noted. The data were collected in Microsoft Excel spread sheets and analyzed using Stata (version 11.2, Stata Corp, Texas, U. S. A) software.One hundred and six patients were recruited. The mean time for primary survey USG versus CE arm was (20 ± 10.01 vs. 18 ± 11.03) seconds. USG detected four pneumothorax, one tracheal injury, and one paratracheal hematoma. The mean procedure time USG versus CE arm was (37.3 ± 21.92 vs. 58 ± 32.04) seconds. Eight esophageal intubations were identified in USG arm by POCUS and two in CE arm by EtCO2 values.Integration of POCUS was useful in all three phases of RSI. It identified paratracheal hematoma, tracheal injury, and pneumothorax. It also identified esophageal intubation and confirmed main stem tracheal intubation in less time compared to five-point auscultation and capnography.

SUBMITTER: Mishra PR

PROVIDER: S-EPMC5994849 | biostudies-other | 2018 Apr-Jun

REPOSITORIES: biostudies-other

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Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation.

Mishra Prakash Ranjan PR Bhoi Sanjeev S Sinha Tej Prakash TP

Journal of emergencies, trauma, and shock 20180401 2

<h4>Introduction</h4>Airway and breathing management play critical role in trauma resuscitation. Early identification of esophageal intubation and detection of fatal events is critical. Authors studied the utility of integration of point-of-care ultrasound (POCUS) during different phases of rapid sequence intubation (RSI) in trauma resuscitation.<h4>Methods</h4>It was prospective, randomized single-centered study conducted at the Emergency Department of a level one trauma center. Patients were d ...[more]

PMID: 29937637

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Project description:BackgroundKetamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation.MethodsWe retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups.ResultsIn total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis.ConclusionIn this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.

Project description:Succinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI.This was a prospective randomized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel. Participants were 401 critically ill patients requiring emergent RSI. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade. The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ? 5%, assessed by continuous pulse oxymetry, at any time between the start of the induction sequence and two minutes after the completion of the intubation. A severe oxygen desaturation was defined as a decrease in oxygen saturation ? 5% leading to a saturation value of ? 80%.There was no difference between succinylcholine and rocuronium regarding oxygen desaturations (succinylcholine 73/196; rocuronium 66/195; P = 0.67); severe oxygen desaturations (succinylcholine 20/196; rocuronium 20/195; P = 1.0); and extent of oxygen desaturations (succinylcholine -14 ± 12%; rocuronium -16 ± 13%; P = 0.77). The duration of the intubation sequence was shorter after succinycholine than after rocuronium (81 ± 38 sec versus 95 ± 48 sec; P = 0.002). Intubation conditions (succinylcholine 8.3 ± 0.8; rocuronium 8.2 ± 0.9; P = 0.7) and failed first intubation attempts (succinylcholine 32/200; rocuronium 36/201; P = 1.0) did not differ between the groups.In critically ill patients undergoing emergent RSI, incidence and severity of oxygen desaturations, the quality of intubation conditions, and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium.ClinicalTrials.gov, number NCT00355368.

Project description:Objectives:To determine the feasibility of integrating pre-intubation ultrasound into airway course and assess emergency medicine (EM) residents' confidence and comfort level in using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session. Materials and methods:This is a retrospective study. Pre-intubation ultrasound training was delivered with the following ultrasound components (didactics and hands-on sessions using human models) to EM residents: (1) sonoanatomy and scanning technique to identify cricothyroid membrane and (2) pre-intubation echocardiography for recognition of acute right ventricular failure and pre-intubation hemodynamic stabilization. Results:A total of 56 EM residents participated in this study. Only 21% [95% confidence interval (CI), 10-31%] reported using ultrasound for pre-intubation hemodynamic stabilization. After the training session, 89% (95% CI, 81-97%) reported that ultrasound-based teaching increased their knowledge of pre-intubation hemodynamic stabilization compared with traditional teaching methods. On a scale of 1 (low) through 10 (high), the average comfort level for integrating ultrasound findings into medical decision making for pre-intubation hemodynamic stabilization was 6.8 (95% CI, 6.3-7.3). Seventy-nine percent (95% CI, 68-89%) reported that focused training in airway ultrasound is adequate to identify cricothyroid membrane. On a scale of 1 (low) through 10 (high), the average confidence level for identifying cricothyroid membrane using ultrasound was 6.6 (95% CI, 6.1-7.1). Conclusion:At our institution, we successfully integrated pre-intubation ultrasound into an airway course. Emergency medicine residents had a moderate level of comfort and confidence level using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session. How to cite this article:Adhikari S, Situ-LaCasse E, Acuña J, Irving S, Weaver C, Samsel K, et al. Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program. Indian J Crit Care Med 2020;24(3):179-183.

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Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation.

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Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation.

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