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David B Hoyt - One of the best experts on this subject based on the ideXlab platform.
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the ability of paramedics to predict aspiration in patients undergoing prehospital Rapid Sequence Intubation
Journal of Emergency Medicine, 2006Co-Authors: Tyler F Vadeboncoeur, Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Gary M VilkeAbstract:One of the purported benefits to invasive prehospital airway management is the prevention of aspiration; however, aspiration events may occur before the arrival of prehospital personnel. We explore the timing of aspiration in patients with severe traumatic brain injury (TBI) undergoing paramedic Rapid Sequence Intubation (RSI). Severely head-injured (Glasgow Coma Scale [GCS] score 3-8) adults were prospectively enrolled into the San Diego Paramedic RSI Trial. As part of the prehospital data collection tool, paramedics prospectively assessed for clinical evidence of aspiration before RSI (pre-Intubation), aspiration events occurring during RSI (peri-RSI), and regurgitation of vomitus or blood after Intubation (post-Intubation). Data were abstracted from work sheets used during the RSI procedure, a telephone debriefing by one of the principal investigators immediately after delivery of the patient, and San Diego County prehospital and trauma databases. The incidence of pre-Intubation aspiration, peri-RSI aspiration, and post-Intubation regurgitation of vomitus or blood were determined. Patients with and without pre-Intubation aspiration were compared with regard to pre- and post-Intubation hypoxia and the rate of aspiration pneumonia. Logistic regression was used to explore the association between pre-Intubation aspiration and various demographic and clinical factors. The results showed that pre-Intubation aspiration was noted by paramedics in 72/269 patients in whom complete data were available. Peri-RSI aspiration was reported in one patient; there were no reported cases of post-Intubation regurgitation of vomitus or blood. Patients in the pre-Intubation aspiration group required more Intubation attempts, had a higher incidence of desaturations and lower pre- and post-Intubation SaO(2) values, and were more frequently diagnosed with aspiration pneumonia. Pre-Intubation aspiration was associated with severe TBI, GCS score of 3, younger age, and the absence of alcohol intoxication despite controlling for age, gender, GCS, Head AIS (Abbreviated Injury Score), and serum ethanol. It is concluded that paramedics seem to be able to accurately assess for aspiration in patients undergoing prehospital RSI. The vast majority of aspiration events seem to occur before the arrival of prehospital personnel. Alteration in consciousness from TBI may carry a higher risk of aspiration than with other causes, such as alcohol intoxication.
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a follow up analysis of factors associated with head injury mortality after paramedic Rapid Sequence Intubation
Journal of Trauma-injury Infection and Critical Care, 2005Co-Authors: Daniel P Davis, Jessica Stern, Michael J Sise, David B HoytAbstract:Background: The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality after paramedic RSI, with hyperventilation identified as a contributing factor in a small subgroup analysis. Here we explore factors affecting outcome in the entire cohort of patients undergoing paramedic RSI to confirm previous findings. This also represents a synthesis of findings from previous analyses Methods: Adult trauma patients with severe head injury (Glasgow Coma Scale score, 3-8) who could not be intubated without RSI were prospectively enrolled in the trial. This analysis excluded patients without traumatic brain injury (head/neck abbreviated injury score <2 or failure to meet Major Trauma Outcome Study criteria) or death in the field or within 30 minutes of arrival. Each remaining trial patient was matched to two nonintubated historical controls from the county trauma registry based on: age, sex, mechanism, abbreviated injury scores for each body system, and Injury Severity Score. Logistic regression, cohort analysis, mean least squares regression, and discordant group analysis were used to explore the impact of various factors on outcome. Results: Of the 426 trial patients, 352 met inclusion criteria for this analysis and were hand-matched to 704 controls. Trial patients and controls were identical with regard to all matching variables. Mortality was increased in RSI patients versus matched controls (31.8 versus 23.7%; odds ration, 1.5; 95% confidence interval, 1.1-2.0; p < 0.01). Hyperventilation was associated with an increase in mortality, whereas transport by aeromedical crews after paramedic RSI was associated with improved outcomes. The reported incidence of aspiration pneumonia was higher for the RSI patients. Conclusion: Paramedic RSI was associated with an increase in mortality compared with matched historical controls. The association between hyperventilation and mortality was confirmed. In addition, patients transported by helicopter after paramedic RSI had improved outcomes. Paramedic RSI did not seem to prevent aspiration pneumonia.
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ventilation patterns in patients with severe traumatic brain injury following paramedic Rapid Sequence Intubation
Neurocritical Care, 2005Co-Authors: Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Robyn R Heister, James V DunfordAbstract:Introduction: Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic Rapid Sequence Intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring. Methods: Adult patients with severe head injury (Glasgow Coma Score: 3–8) unable to be intubated without RSI were prospectively enrolled in the trial. Midazolam and succinylcholine were used for RSI; rocuronium was administered following tube confirmation. Standardized ventilation protocols were used by most paramedics; however, one agency instituted ETCO2 monitoring during the second trial year, with paramedics instructed to target ETCO2 values of 30 to 35 mmHg. The incidence and duration of inadvertent hyperventilation (ETCO2:<30 mmHg) and severe hyperventilation (ETCO2:<25 mmHg) were explored for patients undergoing ETCO2 monitoring. The initial, final, minimum, and maximum values for ETCO2 and the maximum and minimum ventilatory rate values were also calculated using descriptive statistics (95% confidence interval). The pattern of ETCO2 values over time and distribution of recorded ventilatory rate values were explored graphically. Results: A total of 76 trial patients had adequate ETCO2 data for this analysis. The mean values for initial, final, maximum, and minimum ETCO2 were 40.8 (range: 37.5–44.2), 28.4 (range: 25.4–31.4), 45.1 (range: 41.4–48.8), and 23.5 mmHg (range: 21.4–25.5), respectively. The mean maximum and minimum ventilatory rate values were 36.0/minute (range: 33.5–38.5) and 12.8/minute (range: 11.9–13.7), respectively. ETCO2 values less than 30 and 25 mmHg were documented in 79% and 59% of patients, respectively, with mean durations of 485 (range: 378–592) and 390 seconds (range: 285–494). Conclusion: Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.
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air medical transport of severely head injured patients undergoing paramedic Rapid Sequence Intubation
Air Medical Journal, 2004Co-Authors: Jennifer C Poste, Daniel P Davis, Mel Ochs, Gary M Vilke, Edward M Castillo, Jessica Stern, David B HoytAbstract:Abstract Introduction The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury. This analysis explores the impact of air medical transport of trial patients on outcome. Methods Adult trauma victims with severe traumatic brain injury (Glasgow Coma Scale score of 3 to 8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; air medical crews could be called at the discretion of ground paramedics, generally for anticipated prolonged transports. Patients were matched to historical controls using the following parameters: age, gender, mechanism, injury of severity score, and abbreviated injury scale scores for each body system. Patients transported by air and ground were compared with regard to demographics, clinical parameters, vital signs, arterial blood gas data, and outcome. Results A total of 336 patients were included (79 air medical and 257 ground transports). No significant differences arose between the groups with regard to demographic, clinical, vital sign, and arterial blood gas data. Air medical patients had decreased mortality (28% vs 31%, OR 0.9), and ground patients had increased mortality versus matched controls (33% vs 22%, OR 1.8). Discordant groups analysis revealed a statistically significant effect of transport personnel on outcome (P= .009). Neither advanced procedures nor the use of mannitol accounted for the improved outcomes; air medical crews used capnometry to guide ventilation on all study patients. Conclusion Air medical transport of severely head-injured patients undergoing paramedic RSI was associated with improved outcomes. Improved ventilation by capnometry may account for part of these improvements.
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the impact of hypoxia and hyperventilation on outcome after paramedic Rapid Sequence Intubation of severely head injured patients
Journal of Trauma-injury Infection and Critical Care, 2004Co-Authors: Daniel P Davis, Mel Ochs, Jennifer C Poste, James V Dunford, Dale Fortlage, Troy L Holbrook, Michael J Size, Frank Kennedy, David B HoytAbstract:Background:An increase in mortality has been documented in association with paramedic Rapid Sequence Intubation (RSI) of severely head-injured patients. This analysis explores the impact of hypoxia and hyperventilation on outcome.Methods:Adult severely head-injured patients (Glasgow Coma Scale score
Daniel P Davis - One of the best experts on this subject based on the ideXlab platform.
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rate of decline in oxygen saturation at various pulse oximetry values with prehospital Rapid Sequence Intubation
Prehospital Emergency Care, 2008Co-Authors: Daniel P Davis, James Q Hwang, James V DunfordAbstract:Background. A high incidence of desaturations has been observed during prehospital Rapid Sequence Intubation (RSI). The rate of decline in oxygen saturation (SpO2) at various pulse oximetry values has not been defined with emergency RSI. Objective. To define the rate of SpO2 decline at various pulse oximetry values andidentify a threshold below which active BVM should be performed during prehospital RSI. Methods. Traumatic brain injury (TBI) patients undergoing RSI by prehospital providers were included in this analysis. The time period from the highest to the lowest preIntubation SpO2 value was selected for review. The mean rate of SpO2 decline was calculated for each SpO2 value andthen used to define a theoretical SpO2 desaturation curve. The rate of desaturation to hypoxemia (SpO2 ≤ 90%) was defined for Intubation attempts initiated at each SpO2 value. Results. A total of 684 SpO2 values from 87 patients were included. Lower SpO2 values were associated with a faster rate of SpO2 decline, with an inflec...
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paramedic Rapid Sequence Intubation for severe traumatic brain injury perspectives from an expert panel
Prehospital Emergency Care, 2007Co-Authors: Daniel P Davis, Eileen M Bulger, Samir M Fakhry, Henry E Wang, Robert M Domeier, Arthur L Trask, Grant V Bochicchio, William E Hauda, Linda RobinsonAbstract:Although early Intubation has become standard practice in the prehospital management of severe traumatic brain injury (TBI), many patients cannot be intubated without neuromuscular blockade. Several emergency medical services (EMS) systems have implemented paramedic Rapid Sequence Intubation (RSI) protocols, with published reports documenting apparently conflicting outcomes effects. In response, the Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI andoffer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, andapparent differences in outcome can be explained by use of different methodologies andvariability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to r...
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the ability of paramedics to predict aspiration in patients undergoing prehospital Rapid Sequence Intubation
Journal of Emergency Medicine, 2006Co-Authors: Tyler F Vadeboncoeur, Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Gary M VilkeAbstract:One of the purported benefits to invasive prehospital airway management is the prevention of aspiration; however, aspiration events may occur before the arrival of prehospital personnel. We explore the timing of aspiration in patients with severe traumatic brain injury (TBI) undergoing paramedic Rapid Sequence Intubation (RSI). Severely head-injured (Glasgow Coma Scale [GCS] score 3-8) adults were prospectively enrolled into the San Diego Paramedic RSI Trial. As part of the prehospital data collection tool, paramedics prospectively assessed for clinical evidence of aspiration before RSI (pre-Intubation), aspiration events occurring during RSI (peri-RSI), and regurgitation of vomitus or blood after Intubation (post-Intubation). Data were abstracted from work sheets used during the RSI procedure, a telephone debriefing by one of the principal investigators immediately after delivery of the patient, and San Diego County prehospital and trauma databases. The incidence of pre-Intubation aspiration, peri-RSI aspiration, and post-Intubation regurgitation of vomitus or blood were determined. Patients with and without pre-Intubation aspiration were compared with regard to pre- and post-Intubation hypoxia and the rate of aspiration pneumonia. Logistic regression was used to explore the association between pre-Intubation aspiration and various demographic and clinical factors. The results showed that pre-Intubation aspiration was noted by paramedics in 72/269 patients in whom complete data were available. Peri-RSI aspiration was reported in one patient; there were no reported cases of post-Intubation regurgitation of vomitus or blood. Patients in the pre-Intubation aspiration group required more Intubation attempts, had a higher incidence of desaturations and lower pre- and post-Intubation SaO(2) values, and were more frequently diagnosed with aspiration pneumonia. Pre-Intubation aspiration was associated with severe TBI, GCS score of 3, younger age, and the absence of alcohol intoxication despite controlling for age, gender, GCS, Head AIS (Abbreviated Injury Score), and serum ethanol. It is concluded that paramedics seem to be able to accurately assess for aspiration in patients undergoing prehospital RSI. The vast majority of aspiration events seem to occur before the arrival of prehospital personnel. Alteration in consciousness from TBI may carry a higher risk of aspiration than with other causes, such as alcohol intoxication.
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a follow up analysis of factors associated with head injury mortality after paramedic Rapid Sequence Intubation
Journal of Trauma-injury Infection and Critical Care, 2005Co-Authors: Daniel P Davis, Jessica Stern, Michael J Sise, David B HoytAbstract:Background: The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality after paramedic RSI, with hyperventilation identified as a contributing factor in a small subgroup analysis. Here we explore factors affecting outcome in the entire cohort of patients undergoing paramedic RSI to confirm previous findings. This also represents a synthesis of findings from previous analyses Methods: Adult trauma patients with severe head injury (Glasgow Coma Scale score, 3-8) who could not be intubated without RSI were prospectively enrolled in the trial. This analysis excluded patients without traumatic brain injury (head/neck abbreviated injury score <2 or failure to meet Major Trauma Outcome Study criteria) or death in the field or within 30 minutes of arrival. Each remaining trial patient was matched to two nonintubated historical controls from the county trauma registry based on: age, sex, mechanism, abbreviated injury scores for each body system, and Injury Severity Score. Logistic regression, cohort analysis, mean least squares regression, and discordant group analysis were used to explore the impact of various factors on outcome. Results: Of the 426 trial patients, 352 met inclusion criteria for this analysis and were hand-matched to 704 controls. Trial patients and controls were identical with regard to all matching variables. Mortality was increased in RSI patients versus matched controls (31.8 versus 23.7%; odds ration, 1.5; 95% confidence interval, 1.1-2.0; p < 0.01). Hyperventilation was associated with an increase in mortality, whereas transport by aeromedical crews after paramedic RSI was associated with improved outcomes. The reported incidence of aspiration pneumonia was higher for the RSI patients. Conclusion: Paramedic RSI was associated with an increase in mortality compared with matched historical controls. The association between hyperventilation and mortality was confirmed. In addition, patients transported by helicopter after paramedic RSI had improved outcomes. Paramedic RSI did not seem to prevent aspiration pneumonia.
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ventilation patterns in patients with severe traumatic brain injury following paramedic Rapid Sequence Intubation
Neurocritical Care, 2005Co-Authors: Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Robyn R Heister, James V DunfordAbstract:Introduction: Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic Rapid Sequence Intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring. Methods: Adult patients with severe head injury (Glasgow Coma Score: 3–8) unable to be intubated without RSI were prospectively enrolled in the trial. Midazolam and succinylcholine were used for RSI; rocuronium was administered following tube confirmation. Standardized ventilation protocols were used by most paramedics; however, one agency instituted ETCO2 monitoring during the second trial year, with paramedics instructed to target ETCO2 values of 30 to 35 mmHg. The incidence and duration of inadvertent hyperventilation (ETCO2:<30 mmHg) and severe hyperventilation (ETCO2:<25 mmHg) were explored for patients undergoing ETCO2 monitoring. The initial, final, minimum, and maximum values for ETCO2 and the maximum and minimum ventilatory rate values were also calculated using descriptive statistics (95% confidence interval). The pattern of ETCO2 values over time and distribution of recorded ventilatory rate values were explored graphically. Results: A total of 76 trial patients had adequate ETCO2 data for this analysis. The mean values for initial, final, maximum, and minimum ETCO2 were 40.8 (range: 37.5–44.2), 28.4 (range: 25.4–31.4), 45.1 (range: 41.4–48.8), and 23.5 mmHg (range: 21.4–25.5), respectively. The mean maximum and minimum ventilatory rate values were 36.0/minute (range: 33.5–38.5) and 12.8/minute (range: 11.9–13.7), respectively. ETCO2 values less than 30 and 25 mmHg were documented in 79% and 59% of patients, respectively, with mean durations of 485 (range: 378–592) and 390 seconds (range: 285–494). Conclusion: Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.
Mel Ochs - One of the best experts on this subject based on the ideXlab platform.
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the ability of paramedics to predict aspiration in patients undergoing prehospital Rapid Sequence Intubation
Journal of Emergency Medicine, 2006Co-Authors: Tyler F Vadeboncoeur, Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Gary M VilkeAbstract:One of the purported benefits to invasive prehospital airway management is the prevention of aspiration; however, aspiration events may occur before the arrival of prehospital personnel. We explore the timing of aspiration in patients with severe traumatic brain injury (TBI) undergoing paramedic Rapid Sequence Intubation (RSI). Severely head-injured (Glasgow Coma Scale [GCS] score 3-8) adults were prospectively enrolled into the San Diego Paramedic RSI Trial. As part of the prehospital data collection tool, paramedics prospectively assessed for clinical evidence of aspiration before RSI (pre-Intubation), aspiration events occurring during RSI (peri-RSI), and regurgitation of vomitus or blood after Intubation (post-Intubation). Data were abstracted from work sheets used during the RSI procedure, a telephone debriefing by one of the principal investigators immediately after delivery of the patient, and San Diego County prehospital and trauma databases. The incidence of pre-Intubation aspiration, peri-RSI aspiration, and post-Intubation regurgitation of vomitus or blood were determined. Patients with and without pre-Intubation aspiration were compared with regard to pre- and post-Intubation hypoxia and the rate of aspiration pneumonia. Logistic regression was used to explore the association between pre-Intubation aspiration and various demographic and clinical factors. The results showed that pre-Intubation aspiration was noted by paramedics in 72/269 patients in whom complete data were available. Peri-RSI aspiration was reported in one patient; there were no reported cases of post-Intubation regurgitation of vomitus or blood. Patients in the pre-Intubation aspiration group required more Intubation attempts, had a higher incidence of desaturations and lower pre- and post-Intubation SaO(2) values, and were more frequently diagnosed with aspiration pneumonia. Pre-Intubation aspiration was associated with severe TBI, GCS score of 3, younger age, and the absence of alcohol intoxication despite controlling for age, gender, GCS, Head AIS (Abbreviated Injury Score), and serum ethanol. It is concluded that paramedics seem to be able to accurately assess for aspiration in patients undergoing prehospital RSI. The vast majority of aspiration events seem to occur before the arrival of prehospital personnel. Alteration in consciousness from TBI may carry a higher risk of aspiration than with other causes, such as alcohol intoxication.
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ventilation patterns in patients with severe traumatic brain injury following paramedic Rapid Sequence Intubation
Neurocritical Care, 2005Co-Authors: Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Robyn R Heister, James V DunfordAbstract:Introduction: Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic Rapid Sequence Intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring. Methods: Adult patients with severe head injury (Glasgow Coma Score: 3–8) unable to be intubated without RSI were prospectively enrolled in the trial. Midazolam and succinylcholine were used for RSI; rocuronium was administered following tube confirmation. Standardized ventilation protocols were used by most paramedics; however, one agency instituted ETCO2 monitoring during the second trial year, with paramedics instructed to target ETCO2 values of 30 to 35 mmHg. The incidence and duration of inadvertent hyperventilation (ETCO2:<30 mmHg) and severe hyperventilation (ETCO2:<25 mmHg) were explored for patients undergoing ETCO2 monitoring. The initial, final, minimum, and maximum values for ETCO2 and the maximum and minimum ventilatory rate values were also calculated using descriptive statistics (95% confidence interval). The pattern of ETCO2 values over time and distribution of recorded ventilatory rate values were explored graphically. Results: A total of 76 trial patients had adequate ETCO2 data for this analysis. The mean values for initial, final, maximum, and minimum ETCO2 were 40.8 (range: 37.5–44.2), 28.4 (range: 25.4–31.4), 45.1 (range: 41.4–48.8), and 23.5 mmHg (range: 21.4–25.5), respectively. The mean maximum and minimum ventilatory rate values were 36.0/minute (range: 33.5–38.5) and 12.8/minute (range: 11.9–13.7), respectively. ETCO2 values less than 30 and 25 mmHg were documented in 79% and 59% of patients, respectively, with mean durations of 485 (range: 378–592) and 390 seconds (range: 285–494). Conclusion: Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.
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air medical transport of severely head injured patients undergoing paramedic Rapid Sequence Intubation
Air Medical Journal, 2004Co-Authors: Jennifer C Poste, Daniel P Davis, Mel Ochs, Gary M Vilke, Edward M Castillo, Jessica Stern, David B HoytAbstract:Abstract Introduction The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury. This analysis explores the impact of air medical transport of trial patients on outcome. Methods Adult trauma victims with severe traumatic brain injury (Glasgow Coma Scale score of 3 to 8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; air medical crews could be called at the discretion of ground paramedics, generally for anticipated prolonged transports. Patients were matched to historical controls using the following parameters: age, gender, mechanism, injury of severity score, and abbreviated injury scale scores for each body system. Patients transported by air and ground were compared with regard to demographics, clinical parameters, vital signs, arterial blood gas data, and outcome. Results A total of 336 patients were included (79 air medical and 257 ground transports). No significant differences arose between the groups with regard to demographic, clinical, vital sign, and arterial blood gas data. Air medical patients had decreased mortality (28% vs 31%, OR 0.9), and ground patients had increased mortality versus matched controls (33% vs 22%, OR 1.8). Discordant groups analysis revealed a statistically significant effect of transport personnel on outcome (P= .009). Neither advanced procedures nor the use of mannitol accounted for the improved outcomes; air medical crews used capnometry to guide ventilation on all study patients. Conclusion Air medical transport of severely head-injured patients undergoing paramedic RSI was associated with improved outcomes. Improved ventilation by capnometry may account for part of these improvements.
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the impact of hypoxia and hyperventilation on outcome after paramedic Rapid Sequence Intubation of severely head injured patients
Journal of Trauma-injury Infection and Critical Care, 2004Co-Authors: Daniel P Davis, Mel Ochs, Jennifer C Poste, James V Dunford, Dale Fortlage, Troy L Holbrook, Michael J Size, Frank Kennedy, David B HoytAbstract:Background:An increase in mortality has been documented in association with paramedic Rapid Sequence Intubation (RSI) of severely head-injured patients. This analysis explores the impact of hypoxia and hyperventilation on outcome.Methods:Adult severely head-injured patients (Glasgow Coma Scale score
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the use of quantitative end tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic Rapid Sequence Intubation
Journal of Trauma-injury Infection and Critical Care, 2004Co-Authors: Daniel P Davis, Mel Ochs, James V Dunford, Kenneth Park, David B HoytAbstract:Background: This study aimed to determine whether field end-tidal carbon dioxide CO 2 (ETCO 2 ) monitoring decreases inadvertent severe hyperventilation after paramedic Rapid Sequence Intubation. Methods: Data were collected prospectively as part of the San Diego Paramedic Rapid Sequence Intubation Trial, which enrolled adults with severe head injuries (Glasgow Coma Score, 3-8) that could not be intubated without neuromuscular blockade. After preoxygenation, the patients underwent Rapid Sequence Intubation using midazolam and succinylcholine. A maximum of three Intubation attempts were allowed before Combitube insertion was mandated. Tube confirmation was accomplished by physical examination, qualitative capnometry, pulse oximetry, and syringe aspiration. Standard ventilation parameters (tidal volume, 800 mL; 12 breaths/minute) were taught. One agency used portable ETCO 2 monitors, with ventilation modified to target ETCO 2 values of 30 to 35 mm Hg. Trial patients transported by aeromedical crews also underwent ETCO 2 monitoring. The primary outcome measure was the incidence of inadvertent severe hyperventilation, defined as arterial blood gas partial pressure of CO 2 (pCO 2 ) of less than 25 mm Hg at arrival, for patients with and those without ETCO 2 monitoring. These groups also were compared in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival arterial blood gas data, and survival. Results: The study enrolled 426 patients and administered neuromuscular blocking agents to 418 patients. Endotracheal Intubation was successful for 355 of these patients (85.2%). Another 58 patients (13.6%) underwent Combitube insertion. For 291 successfully intubated patients, arrival pCO 2 values were documented, with continuous ETCO 2 monitoring performed for 144 of these patients (49.4%). Patients with ETCO 2 monitoring had a lower incidence of inadvertent severe hyperventilation than those without ETCO 2 monitoring (5.6% vs. 13.4%; odds ratio, 2.64; 95% confidence interval, 1.12-6.20; p = 0.035). There were no significant differences in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival partial pressure of oxygen (pO 2 ) and pH, or survival. The patients in both groups with severe hyperventilation had a significantly higher mortality rate than the patients without hyperventilation (56 vs. 30%; odds ratio, 2.9; 95% confidence interval, 1.3-6.6; p = 0.016), which could not be explained solely on the basis of their injuries. Conclusions: The use of ETCO 2 monitoring is associated with a decrease in inadvertent severe hyperventilation.
John C Sakles - One of the best experts on this subject based on the ideXlab platform.
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use of end tidal oxygen monitoring to assess preoxygenation during Rapid Sequence Intubation in the emergency department
Annals of Emergency Medicine, 2019Co-Authors: Nicholas D Caputo, Matthew Oliver, Jason R West, Robert Hackett, John C SaklesAbstract:Study objective Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen ( eto 2) during Rapid Sequence Intubation in the emergency department. Methods This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing Rapid Sequence Intubation in the emergency department. A standard gas analyzer was used to measure eto 2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto 2 before preoxygenation and at administration of Rapid Sequence Intubation medications. We also characterized peri-Intubation SpO2, identifying instances of SpO2 less than 90%. Results We included 100 patients during a 6-month period. Median eto 2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto 2 level greater than 85%. Median eto 2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto 2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto 2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 eto 2 level greater than 85% at induction. Conclusion ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing Rapid Sequence Intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.
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effect of patient weight on first pass success and neuromuscular blocking agent dosing for Rapid Sequence Intubation in the emergency department
Emergency Medicine Journal, 2017Co-Authors: Asad E Patanwala, John C SaklesAbstract:Objectives The primary objective of this study was to determine the association between patient weight and first pass success (FPS) during Rapid Sequence Intubation (RSI) in the ED. The secondary objective was to evaluate the association between patient weight and neuromuscular blocking agent (NMBA) dosing. Methods This was a retrospective cohort study conducted in a tertiary care academic ED. Consecutive adult patients who underwent RSI in the ED between January 2014 and June 2016 were included. Data were collected on patient, operator and procedural characteristics. The cohort was categorised into the following weight strata: Results The sample included 891 patients. FPS for each weight category was as follows: Conclusions Very heavy patients (>120 kg) undergoing RSI in the ED had a reduced FPS, and succinylcholine was more commonly underdosed than rocuronium in the heavier weight group.
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maintenance of oxygenation during Rapid Sequence Intubation in the emergency department
Academic Emergency Medicine, 2017Co-Authors: John C SaklesAbstract:Rapid Sequence Intubation (RSI) is the most common method of airway control in the emergency department (ED).1,2 Administration of an anesthetic agent and a neuromuscular blocking agent (NMBA) optimizes conditions for tracheal Intubation and is thought to minimize the risk of aspiration.3-10 Evidence suggests that RSI improves first pass success and reduces complications in the critically ill.11-14 This article is protected by copyright. All rights reserved.
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under dosing of etomidate for Rapid Sequence Intubation in the emergency department
Current Clinical Pharmacology, 2013Co-Authors: Brittany R Traylor, Asad E Patanwala, John C Sakles, Brian L ErstadAbstract:Objective: The objective of this study was to determine if patients who weigh ≥100 kg are more likely to receive under-dosing of etomidate compared to those who weigh <100 kg for Rapid Sequence Intubation in the emergency department (ED). Methods: This was a retrospective cohort study conducted in an academic ED in the United States. Adult patients who received etomidate for Rapid Sequence Intubation were evaluated and categorized into two groups based on weight: 1) <100 kg or 2) ≥100 kg. The mean dose of etomidate (mg/kg) was compared between the groups using an unpaired Student’s t-test. The percentage of patients who received under-dosing (less than 0.2 mg/kg) was compared between groups using the Chi-squared test. Results: A total of 200 patients were included in the final analyses (100 patients in the <100 kg group and 100 patients in the ≥100 kg group). There were no baseline differences in age, sex, paralytic used, or trauma status between the treatment groups. The mean etomidate dose (mg/kg ± standard deviation) was significantly lower in the ≥100 kg group compared to the <100 kg group (0.18 ± 0.03 vs. 0.28 ± 0.07, respectively; p<0.001). There were significantly more patients in the ≥100 kg group who received under-dosing of etomidate compared to the <100 kg group (68% vs. 2%, respectively; p<0.001). Conclusions: Patients who weigh ≥100 kg are more likely to receive under-dosing of etomidate compared to those who weigh <100 kg for Rapid Sequence Intubation in the ED.
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a comparison of succinylcholine and rocuronium for Rapid Sequence Intubation of emergency department patients
Academic Emergency Medicine, 2000Co-Authors: Erik G Laurin, John C Sakles, Edward A Panacek, Aaron A Rantapaa, Jason ReddAbstract:Objective: To compare rocuronium and succinylcholine for Rapid-Sequence Intubation (RSI) in the emergency department (ED). Methods: A one- year prospective cohort comparison study was per- formed using a data collection form completed at the time of Intubation. Data collected included the reason for the neuromuscular-blocking agent (NMBA) cho- sen, the time to onset of paralysis, and any compli- cations encountered. Three ten-point numerical de- scriptor scales recorded the degree of body movement, vocal cord movement, and the physician's overall sat- isfaction with the extent of paralysis. Results: Suc- cinylcholine was used in 382 patients and rocuronium was used in 138 (26% of all RSI) patients. The mean (6 SD) times of onset of succinylcholine and rocuron- ium were 39 6 13 sec and 44 6 20 sec, respectively (p = 0.04). No patient desaturated and required as- sisted ventilations while waiting for paralysis to oc- cur. Types of body movements were similar with the two agents, but less frequent with succinylcholine (median = 10, mean = 9.5 6 1.1) than rocuronium
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rate of decline in oxygen saturation at various pulse oximetry values with prehospital Rapid Sequence Intubation
Prehospital Emergency Care, 2008Co-Authors: Daniel P Davis, James Q Hwang, James V DunfordAbstract:Background. A high incidence of desaturations has been observed during prehospital Rapid Sequence Intubation (RSI). The rate of decline in oxygen saturation (SpO2) at various pulse oximetry values has not been defined with emergency RSI. Objective. To define the rate of SpO2 decline at various pulse oximetry values andidentify a threshold below which active BVM should be performed during prehospital RSI. Methods. Traumatic brain injury (TBI) patients undergoing RSI by prehospital providers were included in this analysis. The time period from the highest to the lowest preIntubation SpO2 value was selected for review. The mean rate of SpO2 decline was calculated for each SpO2 value andthen used to define a theoretical SpO2 desaturation curve. The rate of desaturation to hypoxemia (SpO2 ≤ 90%) was defined for Intubation attempts initiated at each SpO2 value. Results. A total of 684 SpO2 values from 87 patients were included. Lower SpO2 values were associated with a faster rate of SpO2 decline, with an inflec...
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ventilation patterns in patients with severe traumatic brain injury following paramedic Rapid Sequence Intubation
Neurocritical Care, 2005Co-Authors: Daniel P Davis, Mel Ochs, David B Hoyt, Jennifer C Poste, Robyn R Heister, James V DunfordAbstract:Introduction: Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic Rapid Sequence Intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring. Methods: Adult patients with severe head injury (Glasgow Coma Score: 3–8) unable to be intubated without RSI were prospectively enrolled in the trial. Midazolam and succinylcholine were used for RSI; rocuronium was administered following tube confirmation. Standardized ventilation protocols were used by most paramedics; however, one agency instituted ETCO2 monitoring during the second trial year, with paramedics instructed to target ETCO2 values of 30 to 35 mmHg. The incidence and duration of inadvertent hyperventilation (ETCO2:<30 mmHg) and severe hyperventilation (ETCO2:<25 mmHg) were explored for patients undergoing ETCO2 monitoring. The initial, final, minimum, and maximum values for ETCO2 and the maximum and minimum ventilatory rate values were also calculated using descriptive statistics (95% confidence interval). The pattern of ETCO2 values over time and distribution of recorded ventilatory rate values were explored graphically. Results: A total of 76 trial patients had adequate ETCO2 data for this analysis. The mean values for initial, final, maximum, and minimum ETCO2 were 40.8 (range: 37.5–44.2), 28.4 (range: 25.4–31.4), 45.1 (range: 41.4–48.8), and 23.5 mmHg (range: 21.4–25.5), respectively. The mean maximum and minimum ventilatory rate values were 36.0/minute (range: 33.5–38.5) and 12.8/minute (range: 11.9–13.7), respectively. ETCO2 values less than 30 and 25 mmHg were documented in 79% and 59% of patients, respectively, with mean durations of 485 (range: 378–592) and 390 seconds (range: 285–494). Conclusion: Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.
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the impact of hypoxia and hyperventilation on outcome after paramedic Rapid Sequence Intubation of severely head injured patients
Journal of Trauma-injury Infection and Critical Care, 2004Co-Authors: Daniel P Davis, Mel Ochs, Jennifer C Poste, James V Dunford, Dale Fortlage, Troy L Holbrook, Michael J Size, Frank Kennedy, David B HoytAbstract:Background:An increase in mortality has been documented in association with paramedic Rapid Sequence Intubation (RSI) of severely head-injured patients. This analysis explores the impact of hypoxia and hyperventilation on outcome.Methods:Adult severely head-injured patients (Glasgow Coma Scale score
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the use of quantitative end tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic Rapid Sequence Intubation
Journal of Trauma-injury Infection and Critical Care, 2004Co-Authors: Daniel P Davis, Mel Ochs, James V Dunford, Kenneth Park, David B HoytAbstract:Background: This study aimed to determine whether field end-tidal carbon dioxide CO 2 (ETCO 2 ) monitoring decreases inadvertent severe hyperventilation after paramedic Rapid Sequence Intubation. Methods: Data were collected prospectively as part of the San Diego Paramedic Rapid Sequence Intubation Trial, which enrolled adults with severe head injuries (Glasgow Coma Score, 3-8) that could not be intubated without neuromuscular blockade. After preoxygenation, the patients underwent Rapid Sequence Intubation using midazolam and succinylcholine. A maximum of three Intubation attempts were allowed before Combitube insertion was mandated. Tube confirmation was accomplished by physical examination, qualitative capnometry, pulse oximetry, and syringe aspiration. Standard ventilation parameters (tidal volume, 800 mL; 12 breaths/minute) were taught. One agency used portable ETCO 2 monitors, with ventilation modified to target ETCO 2 values of 30 to 35 mm Hg. Trial patients transported by aeromedical crews also underwent ETCO 2 monitoring. The primary outcome measure was the incidence of inadvertent severe hyperventilation, defined as arterial blood gas partial pressure of CO 2 (pCO 2 ) of less than 25 mm Hg at arrival, for patients with and those without ETCO 2 monitoring. These groups also were compared in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival arterial blood gas data, and survival. Results: The study enrolled 426 patients and administered neuromuscular blocking agents to 418 patients. Endotracheal Intubation was successful for 355 of these patients (85.2%). Another 58 patients (13.6%) underwent Combitube insertion. For 291 successfully intubated patients, arrival pCO 2 values were documented, with continuous ETCO 2 monitoring performed for 144 of these patients (49.4%). Patients with ETCO 2 monitoring had a lower incidence of inadvertent severe hyperventilation than those without ETCO 2 monitoring (5.6% vs. 13.4%; odds ratio, 2.64; 95% confidence interval, 1.12-6.20; p = 0.035). There were no significant differences in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival partial pressure of oxygen (pO 2 ) and pH, or survival. The patients in both groups with severe hyperventilation had a significantly higher mortality rate than the patients without hyperventilation (56 vs. 30%; odds ratio, 2.9; 95% confidence interval, 1.3-6.6; p = 0.016), which could not be explained solely on the basis of their injuries. Conclusions: The use of ETCO 2 monitoring is associated with a decrease in inadvertent severe hyperventilation.
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incidence of transient hypoxia and pulse rate reactivity during paramedic Rapid Sequence Intubation
Annals of Emergency Medicine, 2003Co-Authors: James V Dunford, Daniel P Davis, Mel Ochs, Michael K Doney, David B HoytAbstract:Abstract Study objective We determine the incidence of desaturation and pulse rate reactivity during paramedic Rapid Sequence Intubation of patients with severe head injuries (Glasgow Coma Scale score ≤8). Methods Adult patients with severe head injuries had recording oximeter-capnometers applied before Rapid Sequence Intubation. Desaturation was defined as a reduction in oxygen saturation (Spo 2 ) to less than 90% from an initial Spo 2 of greater than or equal to 90% or a decrease from a baseline of less than 90%. Event records were analyzed with emergency medical services (EMS) run sheets and debriefing reports. Results Thirty-one (57%) of 54 patients demonstrated desaturation during Rapid Sequence Intubation. Twenty-six (84%) of these 31 events occurred in patients whose initial Spo 2 value with basic airway skills was greater than or equal to 90%. The median duration of desaturation was 160 seconds (interquartile range 48 to 272 seconds), and the median decrease in Spo 2 was 22%. Six (19%) patients experienced marked bradycardia (pulse rate Conclusion Out-of-hospital Rapid Sequence Intubation by paramedics was complicated by a concerning incidence of desaturation and bradycardia. Paramedic reports did not reflect the presence of these concerning derangements. Most patients had acceptable Spo 2 values before Rapid Sequence Intubation. An effective strategy for preoxygenation is needed before it can be concluded that Rapid Sequence Intubation is of value in the out-of-hospital care of patients with serious closed head injury.
