Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

Burgess, Mark R; Crewdson, Kate; Lockey, David; Perkins, Zane

doi:10.1136/emermed-2017-206592

Cited by 28 publications

(25 citation statements)

References 15 publications

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“… 3 A growing number of emergency medical services are providing this. 4 At present, it is estimated that one in five patients with severe TBI undergo PHEA. 5 …”

Section: Introductionmentioning

confidence: 99%

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Price¹,

Sandbach²,

Ercole

et al. 2020

Emerg Med J

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ObjectivesIn the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0–4.5 kPa (30.0–33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO2–PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO2–PaCO2 gradient of TBI patients at hospital arrival.MethodsA retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% CI. ETCO2–PaCO2 gradient data were compared with a two-tailed, unpaired, t-test.Results107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO2–PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and −0.2 (95% CI −0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2–PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg).ConclusionThere is only moderate correlation of ETCO2 and PaCO2 at hospital arrival in patients with serious TBI. The mean ETCO2–PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO2 measurement.

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“… 3 A growing number of emergency medical services are providing this. 4 At present, it is estimated that one in five patients with severe TBI undergo PHEA. 5 …”

Section: Introductionmentioning

confidence: 99%

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Price¹,

Sandbach²,

Ercole

et al. 2020

Emerg Med J

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“…11 Additionally, a recent investigation into the practicality of these devices found decreased first pass success, damage to PPE, delays in intubation, increased provider discomfort 12 while checklists have a strong record of efficiency and success, particularly in acute care medicine. [13][14][15] Our institution had approximately 1 week of lead time prior to the surge. During the lead-up to the surge, this checklist was developed and revised by the emergency department critical care division and several practice-runs were performed, during which time edits were made.…”

Section: Discussionmentioning

confidence: 99%

Prioritising intubator safety in a pandemic: the details matter

et al. 2021

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Our ED-intensive care unit has instituted a new protocol meant to maximise the safety of physicians, nurses and respiratory therapists involved with endotracheal intubation of patients known or suspected of being infected with the novel SARS-CoV-2. The level of detail involved with this checklist is a deviation from standard intubation practices and is likely unfamiliar to most emergency physicians. However, the two-person system used in our department removes the cognitive burden such complexity would otherwise demand and minimises the number of participants that would typically be exposed during endotracheal intubation. We share this checklist to demonstrate to other departments how adopting international airway guidelines to a specific institution can be achieved in order to promote healthcare worker safety.

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“…Both are now routinely used in pre-hospital practice and emergency departments in many areas. In a 2017 survey of UK pre-hospital critical care teams that provided RSI, 80% had an RSI SOP and 83% used a checklist [ 26 ]. These tools promote a shared mental model of the procedure by the attending team, promote planning for any problems encountered and prevent equipment and preparation errors.…”

Section: Methodsmentioning

confidence: 99%

Rapid sequence induction: where did the consensus go?

Avery

Morton

Raitt³

et al. 2021

Scand J Trauma Resusc Emerg Med

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Background Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. Conclusion The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

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Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

Cited by 28 publications

References 15 publications

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Prioritising intubator safety in a pandemic: the details matter

Rapid sequence induction: where did the consensus go?

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