Emergency tracheal intubation immediately following traumatic injury

Mayglothling, Julie; Duane, Therèse M.; Gibbs, Michael; McCunn, Maureen; Legome, Eric; Eastman, Alexander L.; Whelan, James; Shah, Kaushal

doi:10.1097/ta.0b013e31827018a5

Cited by 166 publications

(74 citation statements)

References 83 publications

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“…1,2 Clinical practice guidelines recommend rapid sequence intubation (RSI) as the procedure of choice for intubating acutely-injured patients. 3 Due to their rapid onset and favorable hemodynamic effects, both etomidate and ketamine are used for RSI induction in trauma. 4–10 However, whether one agent should be preferred over the other for RSI of trauma patients remains unclear.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Upchurch

Grijalva

Russ

et al. 2017

Annals of Emergency Medicine

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Study objective Induction doses of etomidate during rapid sequence intubation (RSI) cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for RSI induction. Among adult trauma patients emergently intubated, we compared clinical outcomes among those induced with etomidate and ketamine. Methods The study entailed a retrospective evaluation of a four-year (January 2011–December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing RSI in the ED of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included intensive care unit (ICU)-free days and ventilator-free days (VFD) evaluated with multivariable ordered logistic regression using the same covariates. Results The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared to 17.3% among those induced with etomidate (aOR: 1.41; 95% CI: 0.92, 2.16). Patients induced with ketamine had similar ICU-free-days (aOR: 0.80; 95% CI: 0.63, 1.00) and VFDs (aOR: 0.96; 95% CI: 0.76, 1.20) as compared to patients induced with etomidate. Conclusion In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard RSI induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

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Section: Introductionmentioning

confidence: 99%

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Upchurch

Grijalva

Russ

et al. 2017

Annals of Emergency Medicine

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“…1,2,3 The concern is that, at an unstable cervical segment, the forces of conventional direct laryngoscopy may result in abnormally great (pathologic) motion of the unstable segment and result in cervical cord compression and injury. Although it is certain that cervical spine motion depends on amount of applied force, the in vivo relationship between laryngoscope force and resultant cervical spine motion has not been characterized.…”

Section: Introductionmentioning

confidence: 99%

Intubation Biomechanics

et al. 2014

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Introduction Laryngoscopy and endotracheal intubation in the presence of cervical spine instability may put patients at risk of cervical cord injury. Nevertheless, the biomechanics of intubation (cervical spine motion as a function of applied force) have not been characterized. This study characterized and compared the relationship between laryngoscope force and cervical spine motion using two laryngoscopes hypothesized to differ in force. Methods Fourteen adults undergoing elective surgery were intubated twice (Macintosh, Airtraq). During each intubation, laryngoscope force, cervical spine motion, and glottic view were recorded. Force and motion were referenced to a pre-intubation baseline (stage 1) and were characterized at three stages: stage 2 (laryngoscope introduction); stage 3 (best glottic view); stage 4 (endotracheal tube in trachea). Results Maximal force and motion occurred at stage 3, and differed between the Macintosh and Airtraq: 1) Force: 48.8±15.8 vs. 10.4±2.8 N, respectively; P=0.0001; 2) occiput-C5 extension: 29.5±8.5 vs. 19.1±8.7 degrees, respectively; P=0.0023. Between stages -2 and -3, the motion/force ratio differed between Macintosh and Airtraq: 0.5±0.2 vs. 2.0±1.4 degrees/N, respectively; P=0.0006. Discussion The relationship between laryngoscope force and cervical spine motion is: 1) non-linear and 2) differs between laryngoscopes. Differences between laryngoscopes in motion/force relationships are likely due to: 1) laryngoscope-specific cervical extension needed for intubation, 2) laryngoscope-specific airway displacement/deformation needed for intubation, and 3) cervical spine and airway tissue viscoelastic properties. Cervical spine motion during endotracheal intubation is not directly proportional to force. Low force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion.

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“…[10][11][12] However, tracheal intubation and application of a cervical collar in the setting of unstable cervical spine can potentially exacerbate cervical spinal cord injury. [13][14][15][16] Previous studies suggest that the main movement of the cervical spine during tracheal intubation is extension; the maximum movement occurs in the atlanto-occipital level, followed by atlanto-axial level, and below C3 segments show less movement. 17 18 The study concerning intubation biomechanics in the setting of AOD is rare; most previous relative studies focused on the unstable C1/C2 segment.…”

Section: Introductionmentioning

confidence: 99%

Cadaveric study of movement in the unstable upper cervical spine during emergency management: tracheal intubation and cervical spine immobilisation—a study protocol for a prospective randomised crossover trial

et al. 2017

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IntroductionEmergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and cervical spine immobilisation can potentially exacerbate cervical spinal cord injury. However, the evidence that previous studies have provided remains unclear, due to lack of a direct measurement technique for dural sac's space during dynamic processes. Our study will use myelography method and a wireless human motion tracker to characterise and compare the change of dural sac's space during tracheal intubations and cervical spine immobilisation in the presence of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture.Methods and analysisPerform laryngoscopy and intubation, video laryngoscope intubation, laryngeal tube insertion, fiberoptic intubation and cervical collar application on cadaveric models of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. The change of dural sac's space and the motion of unstable cervical segment are recorded by video fluoroscopy with previously performing myelography, which enables us to directly measure dural sac's space. Simultaneously, the whole cervical spine motion is recorded at a wireless human motion tracker. The maximum dural sac compression and the maximum angulation and distraction of the injured segment are measured by reviewing fluoroscopic and myelography images.Ethics and disseminationThis study protocol has been approved by the Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany. The results will be published in relevant emergency journals and presented at relevant conferences.Trial registration numberDRKS00010499.

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Emergency tracheal intubation immediately following traumatic injury

Cited by 166 publications

References 83 publications

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Intubation Biomechanics

Cadaveric study of movement in the unstable upper cervical spine during emergency management: tracheal intubation and cervical spine immobilisation—a study protocol for a prospective randomised crossover trial

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