Re: [EMS_Research] Re: More Problems with Pedi

October 12, 2004

You know what they say: " Lies, damn lies and statistics " or another way: " Liars

figure and figures lie " . My point is this, we can prove, disprove, support or

go against any stance we choose by manipulating numbers. We all know that if the

patient doesn't fit the criteria of the position you are trying to support you

can simply say they did not meet the inclusion criteria. This particular

research has a very small number (105 in 9 years) of patients in it. It doesn't

take into account the multiple multiples that could be attributed to these

numbers. An example, what do you suppose the percentage of success would be if

the providers had the ability to employ some form of pharmacologically assisted

intubation? Did the physicians in this study utilize meds?, if so then that

would potentially explain the reason for the higher success rates among the

doctors. What about looking at the number of pediatric trauma intubations were

performed by the various providers? Could we improve the numbers by providing

more experience in tertiary facilities with more numbers of these type of

patients? I think that arbitrarily changing accepted pratice based on a single

potentially biased low number study is pretty dangerous. Yes, 67% seems to be a

very unacceptably low number, but, lets just put into the mix (which doesn't

appear to be placed into the equation) that the 33% of the patients who could

not be intubated was either too awake (intact gag) or had some type of

injury/illness that precluded them from being successfully intubated without

medication, wouldn't the numbers prove something different?

The devils advocate

Lee

Re: [EMS_Research] Re: More Problems with Pedi

Well put, Ben. That's exactly what I was trying to say, just worded much

better

-Allan

> I believe that evidence based medicine (EBM) can be a valuable tool for

paramedicine to evaluate and advance new clinical skills. I think it gives us

an ability to argue with physicians in a language they understand and respect.

Our occupation has evolved as a technical field, and is now becoming more

academic and trying to assert itself as a profession, and performing and

critically analysing research literature is something we are going to have to

embrace if we want to continue onwards.

>

> The trouble with prehospital research is that there is very little data

available, and much of that available data is of poor quality. Consider the

recent vasopressin in asystole research that provided data of negligible value.

The problem becomes, when we very little data to support an intervention and

some weak data to refute it, do we act and say, " this is an intervention

paramedics should not be performing in the field " out of fear for our patient's

care, or do we wait cautiously and build a larger base of higher quality data.

>

> It seems that too often we react and restrict or remove a skill before clear

and unequivocal data is published. Research is interpreted by physician groups

within the biases of their preconceptions about paramedic skill and competency.

Consider a service with an 84% intubation success rate using

benzodiazepine-facilitated intubations, that is considering introducing an RSI

protocol with succinylcholine. From this data, we can draw two conclusions:

>

> 1. Our paramedics intubation success rate is woefully poor, and we should

not proceed with introducing succinylcholine, and perhaps consider withdrawing

our benzodiazepine facilitated protocol, because our paramedics cannot intubate

with a success rate comparable to ER physicians or anesthetists.

>

> OR

>

> 2. Our intubation success rate is low with benzodiazepine-facilitation, can

we improve this success rate with the addition of succinylcholine, an improved

training or QI program, or alternate airway adjuncts?

>

> Which of those conclusions are drawn by a physician control group is going

to depend on their individual biases and preconceptions.

>

> I find that often researchers are too willing to draw the first conclusion

than the second.

>

> Ben.

>

October 12, 2004

Lee:

I agree--we don't need to through the baby out with the bath water. But, the

studies are starting to be multiple. The problem is, things that make such

intuitive sense (such as intubation) are starting to show no benefit. How

will we address this in the textbooks?

+++++++++++++++++++++++++++++++++

JAMA. 2000 Feb 9;283(6):783-90. Related Articles, Links

Effect of out-of-hospital pediatric endotracheal intubation on survival and

neurological outcome: a controlled clinical trial.

Gausche M, RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore

PD, McCollough MD, DP, Pratt FD, Seidel JS.

Department of Emergency Medicine, Harbor-UCLA Medical Center, and

Harbor-UCLA Research and Education Institute, Torrance, Calif 90509, USA.

mgausche@...

CONTEXT: Endotracheal intubation (ETI) is widely used for airway management

of children in the out-of-hospital setting, despite a lack of controlled

trials demonstrating a positive effect on survival or neurological outcome.

OBJECTIVE: To compare the survival and neurological outcomes of pediatric

patients treated with bag-valve-mask ventilation (BVM) with those of

patients treated with BVM followed by ETI. DESIGN: Controlled clinical

trial, in which patients were assigned to interventions by calendar day from

March 15, 1994, through January 1, 1997. SETTING: Two large, urban,

rapid-transport emergency medical services (EMS) systems. PARTICIPANTS: A

total of 830 consecutive patients aged 12 years or younger or estimated to

weigh less than 40 kg who required airway management; 820 were available for

follow-up. INTERVENTIONS: Patients were assigned to receive either BVM (odd

days; n = 410) or BVM followed by ETI (even days; n = 420). MAIN OUTCOME

MEASURES: Survival to hospital discharge and neurological status at

discharge from an acute care hospital compared by treatment group. RESULTS:

There was no significant difference in survival between the BVM group

(123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82;

95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good

neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95%

CI, 0.62-1.22). CONCLUSION: These results indicate that the addition of

out-of-hospital ETI to a paramedic scope of practice that already includes

BVM did not improve survival or neurological outcome of pediatric patients

treated in an urban EMS system.

Publication Types:

Clinical Trial

Controlled Clinical Trial

+++++++++++++++++++++++++++++++++

Semin Pediatr Surg. 2001 Feb;10(1):3-6. Related Articles, Links

Prehospital endotracheal intubation for severe head injury in children: a

reappraisal.

A, DiScala C, Foltin G, Tunik M, Markenson D, Welborn C.

Division of Pediatric Surgery, Columbia University College of Physicians &

Surgeons, Harlem Hospital Center, 506 Lenox Ave, 10037 New York, NY, USA.

Controversy exists regarding the efficacy of prehospital assisted

ventilation by endotracheal intubation (ETI) versus bag-valve-mask (BVM) in

serious pediatric head injury. The National Pediatric Trauma Registry

(NPTR-3) data set was analyzed to examine this question. NPTR-3 (n = 31,464)

was queried regarding the demographics, injury mechanism, injury severity,

prehospital interventions, transport mode, mortality rate, injury

complications, procedure and equipment failure or complications, and

functional outcome of seriously head-injured patients (n = 578) with

comparable injury mechanisms and injury severity who received endotracheal

intubation (ETI) (n = 479; 83%) versus those who received BVM (n = 99; 17%).

Mortality rate was virtually identical between the 2 groups (ETI = 48%, BVM

= 48%), although children receiving ETI were significantly older (P < .01),

more often transported by helicopter (P < .01), and more often received

intravenous fluid in the field (P < .05). However, injury complications

affecting nearly every body system or organ (except kidney, gut, and skin)

occurred less often in children receiving ETI (ETI = 58%, BVM = 71%, P <

..05). Procedure and equipment failure or complications, and functional

outcome, were similar between the 2 groups. Prehospital endotracheal

intubation appears to offer no demonstrable survival or functional advantage

when compared with prehospital bag-valve-mask for prehospital assisted

ventilation in serious pediatric head injury. Injury complications appear to

occur somewhat less often among patients intubated in the field.

+++++++++++++++++++++++++++++++++++

J Emerg Med. 2002 Jan;22(1):71-4. Related Articles, Links

Out-of-hospital pediatric intubation by paramedics: the San Diego

experience.

Vilke GM, Steen PJ, AM, Chan TC.

The Department of Emergency Medicine, University of California, San Diego

Medical Center, San Diego, California 92103, USA.

To evaluate pediatric endotracheal intubations by our paramedics, we

performed a retrospective review of a prehospital computer database, quality

assurance reviews, and prehospital run sheets for all patients under 15

years of age who had an endotracheal tube (ETT) placed. During the 4.5-year

study period, 324 pediatric patients had intubation attempts by field

paramedics, of which 264 (82%) were successful and three were reported

esophageal and unrecognized by the paramedic. Two of these esophageal

placements were noted on arrival at the hospital, and one upon turn-over of

patient care to a nurse of an aeromedical service. All three intubations

were deemed esophageal with direct laryngoscopy, and the patients had been

in cardiopulmonary arrest status prior to the intubation. Of the 264

patients who had ETT placed, 99% were endotracheal, while only 1% were

unrecognized esophageal. We conclude that pediatric endotracheal intubation

by out-of-hospital paramedics in an established EMS system has a low

occurrence of unrecognized esophageal placements.

++++++++++++++++++++++++++++++++++++

Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6. Related Articles, Links

Endotracheal intubation in a rural EMS state: procedure utilization and

impact of skills maintenance guidelines.

Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE.

Department of Emergency Medicine, Maine Medical Center, Portland, Maine

04102, USA. burtoj@...

OBJECTIVE: Recent American Heart Association (AHA) guidelines have suggested

that advanced life support (ALS) providers should have " regular field

experience, " defined as six to 12 intubations/year, as a prerequisite to

patient endotracheal intubation (EI). The authors sought to assess the

impact of this guideline on rural emergency medical services (EMS) practice.

METHODS: Statewide EMS records were reviewed for the calendar years

1997-2001. Data reviewed included the number of providers eligible to

perform ALS skills (including EI), number of procedures performed per year

by EMS provider, patient age, gender, and prehospital diagnosis. The

institutional review board approved the study. RESULTS: During the study

period, a total of 957,836 patient encounters occurred with an average of

1,352 ALS providers annually eligible to perform EI. In the five-year

period, there were 5,615 total EI attempts with a range of 37%-42% of

eligible providers annually performing EI. A mean of 18 providers per year

with a range of 1.8%-0.8% of EI-eligible providers annually attempted EI in

more than five patients. One hundred thirty-seven pediatric EI encounters

occurred during the five-year period with an annual range of 1.4%-2.7% of

eligible providers attempting pediatric EI. During the five-year

investigation, EI success rate was reported as 84% by providers with fewer

than five annual intubation encounters and 86% by providers with more than

five encounters. CONCLUSION: Rural EMS providers rarely use EI skills,

particularly in pediatric patients. If recent AHA intubation guidelines are

to be followed in rural EMS settings, a small number of EMS providers will

meet minimum EI utilization requirements.

Publication Types:

Evaluation Studies

+++++++++++++++++++++++++++++++++++

J Trauma. 2003 Mar;54(3):444-53. Related Articles, Links

The effect of paramedic rapid sequence intubation on outcome in patients

with severe traumatic brain injury.

DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P.

Department of Emergency Medicine, UC San Diego, CA 92103-8676, USA.

OBJECTIVE: To evaluate the effect of paramedic rapid sequence intubation

(RSI) on outcome in patients with severe traumatic brain injury. METHODS:

Adult major trauma victims were prospectively enrolled over two years using

the following inclusion criteria: Glasgow Coma Scale (GCS) 3-8, suspected

head injury by mechanism or physical examination, transport time > 10, " and

inability to intubate without RSI. Midazolam and succinylcholine were

administered before laryngoscopy; rocuronium was given after tube placement

was confirmed using physical examination, capnometry, syringe aspiration,

and pulse oximetry. The Combitube was used as a salvage airway device. For

this analysis, trial patients were excluded for absence of a head injury

(Head/Neck AIS score < 2), failure to fulfill major trauma outcome study

criteria, unsuccessful intubation or Combitube insertion, or death in the

field or in the resuscitation suite within 30 " of arrival. Each study

patient was hand matched to three nonintubated historical controls from our

trauma registry using the following parameters: age, sex, mechanism of

injury, trauma center, and AIS score for each body system. Controls were

excluded for Head/Neck AIS defined by a c-spine injury or death in the field

or in the resuscitation suite within 30 " of arrival. chi 2, odds ratios, and

logistic regression were used to investigate the impact of RSI on the

primary outcome measures of mortality and incidence of a " good outcome, "

defined as discharge to home, rehabilitation, psychiatric facility, jail, or

signing out against medical advice. RESULTS: A total of 209 trial patients

were hand matched to 627 controls. The groups were similar with regard to

all matching parameters, admission vital signs, frequency of specific head

injury diagnoses, and incidence of invasive procedures. Mortality was

significantly increased in the trial cohort versus controls for all patients

(33.0% versus 24.2%, p < 0.05) and in those with Head/Neck AIS scores of 3

or greater (41.1% versus 30.3%, p < 0.05). The incidence of a " good outcome "

was lower in the trial cohort versus controls (45.5% versus 57.9%, p <

0.01). Factors that may have contributed to the increase in mortality

include transient hypoxia, inadvertent hyperventilation, and longer scene

times associated with the RSI procedure. CONCLUSION: Paramedic RSI protocols

to facilitate intubation of head-injured patients were associated with an

increase in mortality and decrease in good outcomes versus matched

historical controls.

+++++++++++++++++++++++++++++++++

J Trauma. 2003 Feb;54(2):307-11. Related Articles, Links

Endotracheal intubation in the field does not improve outcome in trauma

patients who present without an acutely lethal traumatic brain injury.

Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM.

R Cowley Shock Trauma Center and University of land Medical

School, Baltimore, 21201, USA. gbochicchio@...

OBJECTIVES: There is an absence of prospective data evaluating the impact of

prehospital intubation in adult trauma patients. Our objectives were to

determine the outcome of trauma patients intubated in the field who did not

have an acutely lethal traumatic brain injury (death within 48 hours)

compared with patients who were intubated immediately on arrival to the

hospital. METHODS: Prospective data were collected on 191 consecutive

patients admitted to the trauma center with a field Glasgow Coma Scale score

< or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either

intubated in the field or intubated immediately at admission to the

hospital. Patients who died within 48 hours of admission and transfers were

excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained

blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight

(41%) of the 191 patients were intubated in the field and 113 (59%) were

intubated immediately at admission. There was no significant difference in

age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or

Injury Severity Score between the two groups. Patients who were intubated in

the field had a significantly higher morbidity (ventilator days, 14.7 vs.

10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs.

11.7) compared with patients intubated on immediate arrival to the hospital

and nearly double the mortality (23% vs. 12.4). Field-intubated patients had

a 1.5 times greater risk of nosocomial pneumonia compared with

hospital-intubated patients. CONCLUSION: Prehospital intubation is

associated with a significant increase in morbidity and mortality in trauma

patients with traumatic brain injury who are admitted to the hospital

without an acutely lethal injury. A randomized, prospective study is

warranted to confirm these results.

++++++++++++++++++++++++++++++++

J Trauma. 2004 Mar;56(3):531-6. Related Articles, Links

Prehospital endotracheal intubation for trauma does not improve survival

over bag-valve-mask ventilation.

Stockinger ZT, McSwain NE Jr.

Department of Surgery SL-22, Tulane University Health Sciences Center, 1430

Tulane Avenue, New Orleans, LA 70112-2699, USA.

stockinger@...

BACKGROUND: Few data exist supporting a survival benefit to prehospital

endotracheal intubation (ETI) over bag-valve-mask ventilation (BVM) in

trauma patients. METHODS: Data were reviewed from all trauma patients

transported to our Level I trauma center receiving prehospital ETI or BVM.

Mortality was adjusted by age, Revised Trauma Score, Injury Severity Score,

and mechanism of injury (penetrating vs. blunt). RESULTS: Of 5,773 patients,

316 (5.5%) had ETI and 217 (3.8%) had BVM. Patients receiving ETI were

significantly more like to die (88.9% vs. 30.9%, p < 0.0001). When corrected

for Injury Severity Score, Revised Trauma Score, and mechanism of injury,

ETI was associated with similar or greater mortality than BVM. ETI patients

had longer prehospital times (22.0 vs. 20.1 minutes, p = 0.0241).

CONCLUSION: In our trauma system, when corrected for mechanism and severity

of anatomic and physiologic injury, ETI confers no survival advantage over

BVM and slightly increases prehospital time.

+++++++++++++++++++++++++++++++++

E. Bledsoe, DO, FACEP

Midlothian, TX

Re: [EMS_Research] Re: More Problems with Pedi

You know what they say: " Lies, damn lies and statistics " or another way:

" Liars figure and figures lie " . My point is this, we can prove, disprove,

support or go against any stance we choose by manipulating numbers. We all

know that if the patient doesn't fit the criteria of the position you are

trying to support you can simply say they did not meet the inclusion

criteria. This particular research has a very small number (105 in 9 years)

of patients in it. It doesn't take into account the multiple multiples that

could be attributed to these numbers. An example, what do you suppose the

percentage of success would be if the providers had the ability to employ

some form of pharmacologically assisted intubation? Did the physicians in

this study utilize meds?, if so then that would potentially explain the

reason for the higher success rates among the doctors. What about looking at

the number of pediatric trauma intubations were performed by the various

providers? Could we improve the numbers by providing more experience in

tertiary facilities with more numbers of these type of patients? I think

that arbitrarily changing accepted pratice based on a single potentially

biased low number study is pretty dangerous. Yes, 67% seems to be a very

unacceptably low number, but, lets just put into the mix (which doesn't

appear to be placed into the equation) that the 33% of the patients who

could not be intubated was either too awake (intact gag) or had some type of

injury/illness that precluded them from being successfully intubated without

medication, wouldn't the numbers prove something different?

The devils advocate

Lee

October 12, 2004

Doc-

I agree that the routine intubation of Pedi's in

respiratory failure does not improve outcome over BVM, but

should we remove this technique from the Paramedics " Bag

of Tricks " due to it's overuse in certain circumstances?

I would still like to control the airways of my head

trauma patients, and have that option open for my

respiratory failure patients, IN EXTREMIS.....

What would you personally authorise for an experienced

Paramedic working under your license?

My current medical director discourages Pedi ETI, but

still gives the Paramedics the choice.....he reviews our

calls and I can't remember anyone having a session in the

woodshed for a long time.....

Regards-

> Lee:

>

> I agree--we don't need to through the baby out with the

> bath water. But, the studies are starting to be multiple.

> The problem is, things that make such intuitive sense

> (such as intubation) are starting to show no benefit. How

> will we address this in the textbooks?

> +++++++++++++++++++++++++++++++++ JAMA. 2000 Feb 9

> ;283(6):783-90. Related Articles, Links

>

> Effect of out-of-hospital pediatric endotracheal

> intubation on survival and neurological outcome: a

> controlled clinical trial.

>

> Gausche M, RJ, Stratton SJ, Haynes BE, Gunter CS,

> Goodrich SM, Poore PD, McCollough MD, DP, Pratt

> FD, Seidel JS.

>

> Department of Emergency Medicine, Harbor-UCLA Medical

> Center, and Harbor-UCLA Research and Education Institute,

> Torrance, Calif 90509, USA. mgausche@...

>

> CONTEXT: Endotracheal intubation (ETI) is widely used for

> airway management of children in the out-of-hospital

> setting, despite a lack of controlled trials

demonstrating

> a positive effect on survival or neurological outcome.

> OBJECTIVE: To compare the survival and neurological

> outcomes of pediatric patients treated with bag-valve-mask

> ventilation (BVM) with those of patients treated with BVM

> followed by ETI. DESIGN: Controlled clinical trial, in

> which patients were assigned to interventions by

calendar

> day from March 15, 1994, through January 1, 1997. SETTING:

> Two large, urban, rapid-transport emergency medical

> services (EMS) systems. PARTICIPANTS: A total of 830

> consecutive patients aged 12 years or younger or estimated

> to weigh less than 40 kg who required airway management;

> 820 were available for follow-up. INTERVENTIONS:

Patients

> were assigned to receive either BVM (odd days; n =

410) or

> BVM followed by ETI (even days; n = 420). MAIN OUTCOME

> MEASURES: Survival to hospital discharge and neurological

> status at discharge from an acute care hospital compared

> by treatment group. RESULTS: There was no significant

> difference in survival between the BVM group (123/404

> [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR],

> 0.82; 95% confidence interval [CI], 0.61-1.11) or in the

> rate of achieving a good neurological outcome (BVM, 92/404

> [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).

> CONCLUSION: These results indicate that the addition of

> out-of-hospital ETI to a paramedic scope of practice that

> already includes BVM did not improve survival or

> neurological outcome of pediatric patients treated in an

> urban EMS system.

>

> Publication Types:

> Clinical Trial

> Controlled Clinical Trial

>

> +++++++++++++++++++++++++++++++++

> Semin Pediatr Surg. 2001 Feb;10(1):3-6. Related Articles,

> Links

>

> Prehospital endotracheal intubation for severe head injury

> in children: a reappraisal.

>

> A, DiScala C, Foltin G, Tunik M, Markenson D,

> Welborn C.

>

> Division of Pediatric Surgery, Columbia University College

> of Physicians & amp; Surgeons, Harlem Hospital Center, 506

> Lenox Ave, 10037 New York, NY, USA.

>

> Controversy exists regarding the efficacy of prehospital

> assisted ventilation by endotracheal intubation (ETI)

> versus bag-valve-mask (BVM) in serious pediatric head

> injury. The National Pediatric Trauma Registry (NPTR-3)

> data set was analyzed to examine this question. NPTR-3 (n

> = 31,464) was queried regarding the demographics, injury

> mechanism, injury severity, prehospital interventions,

> transport mode, mortality rate, injury complications,

> procedure and equipment failure or complications, and

> functional outcome of seriously head-injured patients (n =

> 578) with comparable injury mechanisms and injury severity

> who received endotracheal intubation (ETI) (n = 479;

83%)

> versus those who received BVM (n = 99; 17%). Mortality

> rate was virtually identical between the 2 groups (ETI =

> 48%, BVM = 48%), although children receiving ETI were

> significantly older (P < .01), more often transported by

> helicopter (P < .01), and more often received

intravenous

> fluid in the field (P < .05). However, injury

> complications affecting nearly every body system or organ

> (except kidney, gut, and skin) occurred less often in

> children receiving ETI (ETI = 58%, BVM = 71%, P <

05).

> Procedure and equipment failure or complications, and

> functional outcome, were similar between the 2 groups.

> Prehospital endotracheal intubation appears to offer no

> demonstrable survival or functional advantage when

> compared with prehospital bag-valve-mask for prehospital

> assisted ventilation in serious pediatric head injury.

> Injury complications appear to occur somewhat less often

> among patients intubated in the field.

>

> +++++++++++++++++++++++++++++++++++

> J Emerg Med. 2002 Jan;22(1):71-4. Related Articles, Links

>

> Out-of-hospital pediatric intubation by paramedics: the

> San Diego experience.

>

> Vilke GM, Steen PJ, AM, Chan TC.

>

> The Department of Emergency Medicine, University of

> California, San Diego Medical Center, San Diego,

> California 92103, USA.

>

> To evaluate pediatric endotracheal intubations by our

> paramedics, we performed a retrospective review of a

> prehospital computer database, quality assurance reviews,

> and prehospital run sheets for all patients under 15 years

> of age who had an endotracheal tube (ETT) placed. During

> the 4.5-year study period, 324 pediatric patients had

> intubation attempts by field paramedics, of which 264

> (82%) were successful and three were reported esophageal

> and unrecognized by the paramedic. Two of these esophageal

> placements were noted on arrival at the hospital, and one

> upon turn-over of patient care to a nurse of an

> aeromedical service. All three intubations were deemed

> esophageal with direct laryngoscopy, and the patients

had

> been in cardiopulmonary arrest status prior to the

> intubation. Of the 264 patients who had ETT placed, 99%

> were endotracheal, while only 1% were unrecognized

> esophageal. We conclude that pediatric endotracheal

> intubation by out-of-hospital paramedics in an established

> EMS system has a low occurrence of unrecognized esophageal

> placements.

>

> ++++++++++++++++++++++++++++++++++++

>

> Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6. Related

> Articles, Links

>

> Endotracheal intubation in a rural EMS state: procedure

> utilization and impact of skills maintenance guidelines.

>

> Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE.

>

> Department of Emergency Medicine, Maine Medical Center,

> Portland, Maine 04102, USA. burtoj@...

>

> OBJECTIVE: Recent American Heart Association (AHA)

> guidelines have suggested that advanced life support (ALS)

> providers should have " regular field experience, " defined

> as six to 12 intubations/year, as a prerequisite to

> patient endotracheal intubation (EI). The authors sought

> to assess the impact of this guideline on rural

emergency

> medical services (EMS) practice. METHODS: Statewide EMS

> records were reviewed for the calendar years 1997-2001.

> Data reviewed included the number of providers eligible to

> perform ALS skills (including EI), number of procedures

> performed per year by EMS provider, patient age, gender,

> and prehospital diagnosis. The institutional review

board

> approved the study. RESULTS: During the study period, a

> total of 957,836 patient encounters occurred with an

> average of 1,352 ALS providers annually eligible to

> perform EI. In the five-year period, there were 5,615

> total EI attempts with a range of 37%-42% of eligible

> providers annually performing EI. A mean of 18 providers

> per year with a range of 1.8%-0.8% of EI-eligible

> providers annually attempted EI in more than five

> patients. One hundred thirty-seven pediatric EI

encounters

> occurred during the five-year period with an annual range

> of 1.4%-2.7% of eligible providers attempting pediatric

> EI. During the five-year investigation, EI success rate

> was reported as 84% by providers with fewer than five

> annual intubation encounters and 86% by providers with

> more than five encounters. CONCLUSION: Rural EMS

providers

> rarely use EI skills, particularly in pediatric patients.

> If recent AHA intubation guidelines are to be followed in

> rural EMS settings, a small number of EMS providers will

> meet minimum EI utilization requirements.

>

> Publication Types:

> Evaluation Studies

>

> +++++++++++++++++++++++++++++++++++

> J Trauma. 2003 Mar;54(3):444-53. Related Articles, Links

>

> The effect of paramedic rapid sequence intubation on

> outcome in patients with severe traumatic brain injury.

>

> DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T,

> Marshall LK, Rosen P.

>

> Department of Emergency Medicine, UC San Diego, CA

> 92103-8676, USA.

>

> OBJECTIVE: To evaluate the effect of paramedic rapid

> sequence intubation (RSI) on outcome in patients with

> severe traumatic brain injury. METHODS: Adult major

trauma

> victims were prospectively enrolled over two years using

> the following inclusion criteria: Glasgow Coma Scale (GCS)

> 3-8, suspected head injury by mechanism or physical

> examination, transport time > 10, " and inability to

> intubate without RSI. Midazolam and succinylcholine were

> administered before laryngoscopy; rocuronium was given

> after tube placement was confirmed using physical

> examination, capnometry, syringe aspiration, and pulse

> oximetry. The Combitube was used as a salvage airway

> device. For th

T.A. Dinerman EMTP EMSI EIEIO

October 12, 2004

Doc-

I agree that the routine intubation of Pedi's in

respiratory failure does not improve outcome over BVM, but

should we remove this technique from the Paramedics " Bag

of Tricks " due to it's overuse in certain circumstances?

I would still like to control the airways of my head

trauma patients, and have that option open for my

respiratory failure patients, IN EXTREMIS.....

What would you personally authorise for an experienced

Paramedic working under your license?

My current medical director discourages Pedi ETI, but

still gives the Paramedics the choice.....he reviews our

calls and I can't remember anyone having a session in the

woodshed for a long time.....

Regards-

> Lee:

>

> I agree--we don't need to through the baby out with the

> bath water. But, the studies are starting to be multiple.

> The problem is, things that make such intuitive sense

> (such as intubation) are starting to show no benefit. How

> will we address this in the textbooks?

> +++++++++++++++++++++++++++++++++ JAMA. 2000 Feb 9

> ;283(6):783-90. Related Articles, Links

>

> Effect of out-of-hospital pediatric endotracheal

> intubation on survival and neurological outcome: a

> controlled clinical trial.

>

> Gausche M, RJ, Stratton SJ, Haynes BE, Gunter CS,

> Goodrich SM, Poore PD, McCollough MD, DP, Pratt

> FD, Seidel JS.

>

> Department of Emergency Medicine, Harbor-UCLA Medical

> Center, and Harbor-UCLA Research and Education Institute,

> Torrance, Calif 90509, USA. mgausche@...

>

> CONTEXT: Endotracheal intubation (ETI) is widely used for

> airway management of children in the out-of-hospital

> setting, despite a lack of controlled trials

demonstrating

> a positive effect on survival or neurological outcome.

> OBJECTIVE: To compare the survival and neurological

> outcomes of pediatric patients treated with bag-valve-mask

> ventilation (BVM) with those of patients treated with BVM

> followed by ETI. DESIGN: Controlled clinical trial, in

> which patients were assigned to interventions by

calendar

> day from March 15, 1994, through January 1, 1997. SETTING:

> Two large, urban, rapid-transport emergency medical

> services (EMS) systems. PARTICIPANTS: A total of 830

> consecutive patients aged 12 years or younger or estimated

> to weigh less than 40 kg who required airway management;

> 820 were available for follow-up. INTERVENTIONS:

Patients

> were assigned to receive either BVM (odd days; n =

410) or

> BVM followed by ETI (even days; n = 420). MAIN OUTCOME

> MEASURES: Survival to hospital discharge and neurological

> status at discharge from an acute care hospital compared

> by treatment group. RESULTS: There was no significant

> difference in survival between the BVM group (123/404

> [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR],

> 0.82; 95% confidence interval [CI], 0.61-1.11) or in the

> rate of achieving a good neurological outcome (BVM, 92/404

> [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).

> CONCLUSION: These results indicate that the addition of

> out-of-hospital ETI to a paramedic scope of practice that

> already includes BVM did not improve survival or

> neurological outcome of pediatric patients treated in an

> urban EMS system.

>

> Publication Types:

> Clinical Trial

> Controlled Clinical Trial

>

> +++++++++++++++++++++++++++++++++

> Semin Pediatr Surg. 2001 Feb;10(1):3-6. Related Articles,

> Links

>

> Prehospital endotracheal intubation for severe head injury

> in children: a reappraisal.

>

> A, DiScala C, Foltin G, Tunik M, Markenson D,

> Welborn C.

>

> Division of Pediatric Surgery, Columbia University College

> of Physicians & amp; Surgeons, Harlem Hospital Center, 506

> Lenox Ave, 10037 New York, NY, USA.

>

> Controversy exists regarding the efficacy of prehospital

> assisted ventilation by endotracheal intubation (ETI)

> versus bag-valve-mask (BVM) in serious pediatric head

> injury. The National Pediatric Trauma Registry (NPTR-3)

> data set was analyzed to examine this question. NPTR-3 (n

> = 31,464) was queried regarding the demographics, injury

> mechanism, injury severity, prehospital interventions,

> transport mode, mortality rate, injury complications,

> procedure and equipment failure or complications, and

> functional outcome of seriously head-injured patients (n =

> 578) with comparable injury mechanisms and injury severity

> who received endotracheal intubation (ETI) (n = 479;

83%)

> versus those who received BVM (n = 99; 17%). Mortality

> rate was virtually identical between the 2 groups (ETI =

> 48%, BVM = 48%), although children receiving ETI were

> significantly older (P < .01), more often transported by

> helicopter (P < .01), and more often received

intravenous

> fluid in the field (P < .05). However, injury

> complications affecting nearly every body system or organ

> (except kidney, gut, and skin) occurred less often in

> children receiving ETI (ETI = 58%, BVM = 71%, P <

05).

> Procedure and equipment failure or complications, and

> functional outcome, were similar between the 2 groups.

> Prehospital endotracheal intubation appears to offer no

> demonstrable survival or functional advantage when

> compared with prehospital bag-valve-mask for prehospital

> assisted ventilation in serious pediatric head injury.

> Injury complications appear to occur somewhat less often

> among patients intubated in the field.

>

> +++++++++++++++++++++++++++++++++++

> J Emerg Med. 2002 Jan;22(1):71-4. Related Articles, Links

>

> Out-of-hospital pediatric intubation by paramedics: the

> San Diego experience.

>

> Vilke GM, Steen PJ, AM, Chan TC.

>

> The Department of Emergency Medicine, University of

> California, San Diego Medical Center, San Diego,

> California 92103, USA.

>

> To evaluate pediatric endotracheal intubations by our

> paramedics, we performed a retrospective review of a

> prehospital computer database, quality assurance reviews,

> and prehospital run sheets for all patients under 15 years

> of age who had an endotracheal tube (ETT) placed. During

> the 4.5-year study period, 324 pediatric patients had

> intubation attempts by field paramedics, of which 264

> (82%) were successful and three were reported esophageal

> and unrecognized by the paramedic. Two of these esophageal

> placements were noted on arrival at the hospital, and one

> upon turn-over of patient care to a nurse of an

> aeromedical service. All three intubations were deemed

> esophageal with direct laryngoscopy, and the patients

had

> been in cardiopulmonary arrest status prior to the

> intubation. Of the 264 patients who had ETT placed, 99%

> were endotracheal, while only 1% were unrecognized

> esophageal. We conclude that pediatric endotracheal

> intubation by out-of-hospital paramedics in an established

> EMS system has a low occurrence of unrecognized esophageal

> placements.

>

> ++++++++++++++++++++++++++++++++++++

>

> Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6. Related

> Articles, Links

>

> Endotracheal intubation in a rural EMS state: procedure

> utilization and impact of skills maintenance guidelines.

>

> Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE.

>

> Department of Emergency Medicine, Maine Medical Center,

> Portland, Maine 04102, USA. burtoj@...

>

> OBJECTIVE: Recent American Heart Association (AHA)

> guidelines have suggested that advanced life support (ALS)

> providers should have " regular field experience, " defined

> as six to 12 intubations/year, as a prerequisite to

> patient endotracheal intubation (EI). The authors sought

> to assess the impact of this guideline on rural

emergency

> medical services (EMS) practice. METHODS: Statewide EMS

> records were reviewed for the calendar years 1997-2001.

> Data reviewed included the number of providers eligible to

> perform ALS skills (including EI), number of procedures

> performed per year by EMS provider, patient age, gender,

> and prehospital diagnosis. The institutional review

board

> approved the study. RESULTS: During the study period, a

> total of 957,836 patient encounters occurred with an

> average of 1,352 ALS providers annually eligible to

> perform EI. In the five-year period, there were 5,615

> total EI attempts with a range of 37%-42% of eligible

> providers annually performing EI. A mean of 18 providers

> per year with a range of 1.8%-0.8% of EI-eligible

> providers annually attempted EI in more than five

> patients. One hundred thirty-seven pediatric EI

encounters

> occurred during the five-year period with an annual range

> of 1.4%-2.7% of eligible providers attempting pediatric

> EI. During the five-year investigation, EI success rate

> was reported as 84% by providers with fewer than five

> annual intubation encounters and 86% by providers with

> more than five encounters. CONCLUSION: Rural EMS

providers

> rarely use EI skills, particularly in pediatric patients.

> If recent AHA intubation guidelines are to be followed in

> rural EMS settings, a small number of EMS providers will

> meet minimum EI utilization requirements.

>

> Publication Types:

> Evaluation Studies

>

> +++++++++++++++++++++++++++++++++++

> J Trauma. 2003 Mar;54(3):444-53. Related Articles, Links

>

> The effect of paramedic rapid sequence intubation on

> outcome in patients with severe traumatic brain injury.

>

> DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T,

> Marshall LK, Rosen P.

>

> Department of Emergency Medicine, UC San Diego, CA

> 92103-8676, USA.

>

> OBJECTIVE: To evaluate the effect of paramedic rapid

> sequence intubation (RSI) on outcome in patients with

> severe traumatic brain injury. METHODS: Adult major

trauma

> victims were prospectively enrolled over two years using

> the following inclusion criteria: Glasgow Coma Scale (GCS)

> 3-8, suspected head injury by mechanism or physical

> examination, transport time > 10, " and inability to

> intubate without RSI. Midazolam and succinylcholine were

> administered before laryngoscopy; rocuronium was given

> after tube placement was confirmed using physical

> examination, capnometry, syringe aspiration, and pulse

> oximetry. The Combitube was used as a salvage airway

> device. For th

T.A. Dinerman EMTP EMSI EIEIO

October 12, 2004

Doc-

I agree that the routine intubation of Pedi's in

respiratory failure does not improve outcome over BVM, but

should we remove this technique from the Paramedics " Bag

of Tricks " due to it's overuse in certain circumstances?

I would still like to control the airways of my head

trauma patients, and have that option open for my

respiratory failure patients, IN EXTREMIS.....

What would you personally authorise for an experienced

Paramedic working under your license?

My current medical director discourages Pedi ETI, but

still gives the Paramedics the choice.....he reviews our

calls and I can't remember anyone having a session in the

woodshed for a long time.....

Regards-

> Lee:

>

> I agree--we don't need to through the baby out with the

> bath water. But, the studies are starting to be multiple.

> The problem is, things that make such intuitive sense

> (such as intubation) are starting to show no benefit. How

> will we address this in the textbooks?

> +++++++++++++++++++++++++++++++++ JAMA. 2000 Feb 9

> ;283(6):783-90. Related Articles, Links

>

> Effect of out-of-hospital pediatric endotracheal

> intubation on survival and neurological outcome: a

> controlled clinical trial.

>

> Gausche M, RJ, Stratton SJ, Haynes BE, Gunter CS,

> Goodrich SM, Poore PD, McCollough MD, DP, Pratt

> FD, Seidel JS.

>

> Department of Emergency Medicine, Harbor-UCLA Medical

> Center, and Harbor-UCLA Research and Education Institute,

> Torrance, Calif 90509, USA. mgausche@...

>

> CONTEXT: Endotracheal intubation (ETI) is widely used for

> airway management of children in the out-of-hospital

> setting, despite a lack of controlled trials

demonstrating

> a positive effect on survival or neurological outcome.

> OBJECTIVE: To compare the survival and neurological

> outcomes of pediatric patients treated with bag-valve-mask

> ventilation (BVM) with those of patients treated with BVM

> followed by ETI. DESIGN: Controlled clinical trial, in

> which patients were assigned to interventions by

calendar

> day from March 15, 1994, through January 1, 1997. SETTING:

> Two large, urban, rapid-transport emergency medical

> services (EMS) systems. PARTICIPANTS: A total of 830

> consecutive patients aged 12 years or younger or estimated

> to weigh less than 40 kg who required airway management;

> 820 were available for follow-up. INTERVENTIONS:

Patients

> were assigned to receive either BVM (odd days; n =

410) or

> BVM followed by ETI (even days; n = 420). MAIN OUTCOME

> MEASURES: Survival to hospital discharge and neurological

> status at discharge from an acute care hospital compared

> by treatment group. RESULTS: There was no significant

> difference in survival between the BVM group (123/404

> [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR],

> 0.82; 95% confidence interval [CI], 0.61-1.11) or in the

> rate of achieving a good neurological outcome (BVM, 92/404

> [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).

> CONCLUSION: These results indicate that the addition of

> out-of-hospital ETI to a paramedic scope of practice that

> already includes BVM did not improve survival or

> neurological outcome of pediatric patients treated in an

> urban EMS system.

>

> Publication Types:

> Clinical Trial

> Controlled Clinical Trial

>

> +++++++++++++++++++++++++++++++++

> Semin Pediatr Surg. 2001 Feb;10(1):3-6. Related Articles,

> Links

>

> Prehospital endotracheal intubation for severe head injury

> in children: a reappraisal.

>

> A, DiScala C, Foltin G, Tunik M, Markenson D,

> Welborn C.

>

> Division of Pediatric Surgery, Columbia University College

> of Physicians & amp; Surgeons, Harlem Hospital Center, 506

> Lenox Ave, 10037 New York, NY, USA.

>

> Controversy exists regarding the efficacy of prehospital

> assisted ventilation by endotracheal intubation (ETI)

> versus bag-valve-mask (BVM) in serious pediatric head

> injury. The National Pediatric Trauma Registry (NPTR-3)

> data set was analyzed to examine this question. NPTR-3 (n

> = 31,464) was queried regarding the demographics, injury

> mechanism, injury severity, prehospital interventions,

> transport mode, mortality rate, injury complications,

> procedure and equipment failure or complications, and

> functional outcome of seriously head-injured patients (n =

> 578) with comparable injury mechanisms and injury severity

> who received endotracheal intubation (ETI) (n = 479;

83%)

> versus those who received BVM (n = 99; 17%). Mortality

> rate was virtually identical between the 2 groups (ETI =

> 48%, BVM = 48%), although children receiving ETI were

> significantly older (P < .01), more often transported by

> helicopter (P < .01), and more often received

intravenous

> fluid in the field (P < .05). However, injury

> complications affecting nearly every body system or organ

> (except kidney, gut, and skin) occurred less often in

> children receiving ETI (ETI = 58%, BVM = 71%, P <

05).

> Procedure and equipment failure or complications, and

> functional outcome, were similar between the 2 groups.

> Prehospital endotracheal intubation appears to offer no

> demonstrable survival or functional advantage when

> compared with prehospital bag-valve-mask for prehospital

> assisted ventilation in serious pediatric head injury.

> Injury complications appear to occur somewhat less often

> among patients intubated in the field.

>

> +++++++++++++++++++++++++++++++++++

> J Emerg Med. 2002 Jan;22(1):71-4. Related Articles, Links

>

> Out-of-hospital pediatric intubation by paramedics: the

> San Diego experience.

>

> Vilke GM, Steen PJ, AM, Chan TC.

>

> The Department of Emergency Medicine, University of

> California, San Diego Medical Center, San Diego,

> California 92103, USA.

>

> To evaluate pediatric endotracheal intubations by our

> paramedics, we performed a retrospective review of a

> prehospital computer database, quality assurance reviews,

> and prehospital run sheets for all patients under 15 years

> of age who had an endotracheal tube (ETT) placed. During

> the 4.5-year study period, 324 pediatric patients had

> intubation attempts by field paramedics, of which 264

> (82%) were successful and three were reported esophageal

> and unrecognized by the paramedic. Two of these esophageal

> placements were noted on arrival at the hospital, and one

> upon turn-over of patient care to a nurse of an

> aeromedical service. All three intubations were deemed

> esophageal with direct laryngoscopy, and the patients

had

> been in cardiopulmonary arrest status prior to the

> intubation. Of the 264 patients who had ETT placed, 99%

> were endotracheal, while only 1% were unrecognized

> esophageal. We conclude that pediatric endotracheal

> intubation by out-of-hospital paramedics in an established

> EMS system has a low occurrence of unrecognized esophageal

> placements.

>

> ++++++++++++++++++++++++++++++++++++

>

> Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6. Related

> Articles, Links

>

> Endotracheal intubation in a rural EMS state: procedure

> utilization and impact of skills maintenance guidelines.

>

> Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE.

>

> Department of Emergency Medicine, Maine Medical Center,

> Portland, Maine 04102, USA. burtoj@...

>

> OBJECTIVE: Recent American Heart Association (AHA)

> guidelines have suggested that advanced life support (ALS)

> providers should have " regular field experience, " defined

> as six to 12 intubations/year, as a prerequisite to

> patient endotracheal intubation (EI). The authors sought

> to assess the impact of this guideline on rural

emergency

> medical services (EMS) practice. METHODS: Statewide EMS

> records were reviewed for the calendar years 1997-2001.

> Data reviewed included the number of providers eligible to

> perform ALS skills (including EI), number of procedures

> performed per year by EMS provider, patient age, gender,

> and prehospital diagnosis. The institutional review

board

> approved the study. RESULTS: During the study period, a

> total of 957,836 patient encounters occurred with an

> average of 1,352 ALS providers annually eligible to

> perform EI. In the five-year period, there were 5,615

> total EI attempts with a range of 37%-42% of eligible

> providers annually performing EI. A mean of 18 providers

> per year with a range of 1.8%-0.8% of EI-eligible

> providers annually attempted EI in more than five

> patients. One hundred thirty-seven pediatric EI

encounters

> occurred during the five-year period with an annual range

> of 1.4%-2.7% of eligible providers attempting pediatric

> EI. During the five-year investigation, EI success rate

> was reported as 84% by providers with fewer than five

> annual intubation encounters and 86% by providers with

> more than five encounters. CONCLUSION: Rural EMS

providers

> rarely use EI skills, particularly in pediatric patients.

> If recent AHA intubation guidelines are to be followed in

> rural EMS settings, a small number of EMS providers will

> meet minimum EI utilization requirements.

>

> Publication Types:

> Evaluation Studies

>

> +++++++++++++++++++++++++++++++++++

> J Trauma. 2003 Mar;54(3):444-53. Related Articles, Links

>

> The effect of paramedic rapid sequence intubation on

> outcome in patients with severe traumatic brain injury.

>

> DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T,

> Marshall LK, Rosen P.

>

> Department of Emergency Medicine, UC San Diego, CA

> 92103-8676, USA.

>

> OBJECTIVE: To evaluate the effect of paramedic rapid

> sequence intubation (RSI) on outcome in patients with

> severe traumatic brain injury. METHODS: Adult major

trauma

> victims were prospectively enrolled over two years using

> the following inclusion criteria: Glasgow Coma Scale (GCS)

> 3-8, suspected head injury by mechanism or physical

> examination, transport time > 10, " and inability to

> intubate without RSI. Midazolam and succinylcholine were

> administered before laryngoscopy; rocuronium was given

> after tube placement was confirmed using physical

> examination, capnometry, syringe aspiration, and pulse

> oximetry. The Combitube was used as a salvage airway

> device. For th

T.A. Dinerman EMTP EMSI EIEIO

October 13, 2004

It appears that those with head injuries do worse with prehospital

intubation. There is no need to hyperventilate them--just ventilate and

oxygenate.

E. Bledsoe, DO, FACEP

Midlothian, TX

RE: [EMS_Research] Re: More Problems with Pedi

Doc-

I agree that the routine intubation of Pedi's in

respiratory failure does not improve outcome over BVM, but

should we remove this technique from the Paramedics " Bag

of Tricks " due to it's overuse in certain circumstances?

I would still like to control the airways of my head

trauma patients, and have that option open for my

respiratory failure patients, IN EXTREMIS.....

What would you personally authorise for an experienced

Paramedic working under your license?

My current medical director discourages Pedi ETI, but

still gives the Paramedics the choice.....he reviews our

calls and I can't remember anyone having a session in the

woodshed for a long time.....

Regards-

> Lee:

>

> I agree--we don't need to through the baby out with the bath water.

> But, the studies are starting to be multiple.

> The problem is, things that make such intuitive sense (such as

> intubation) are starting to show no benefit. How will we address this

> in the textbooks?

> +++++++++++++++++++++++++++++++++ JAMA. 2000 Feb 9 ;283(6):783-90.

> Related Articles, Links

>

> Effect of out-of-hospital pediatric endotracheal intubation on

> survival and neurological outcome: a

> controlled clinical trial.

>

> Gausche M, RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM,

> Poore PD, McCollough MD, DP, Pratt FD, Seidel JS.

>

> Department of Emergency Medicine, Harbor-UCLA Medical Center, and

> Harbor-UCLA Research and Education Institute,

> Torrance, Calif 90509, USA. mgausche@...

>

> CONTEXT: Endotracheal intubation (ETI) is widely used for airway

> management of children in the out-of-hospital

> setting, despite a lack of controlled trials

demonstrating

> a positive effect on survival or neurological outcome.

> OBJECTIVE: To compare the survival and neurological outcomes of

> pediatric patients treated with bag-valve-mask ventilation (BVM) with

> those of patients treated with BVM followed by ETI. DESIGN: Controlled

> clinical trial, in

> which patients were assigned to interventions by

calendar

> day from March 15, 1994, through January 1, 1997. SETTING:

> Two large, urban, rapid-transport emergency medical services (EMS)

> systems. PARTICIPANTS: A total of 830 consecutive patients aged 12

> years or younger or estimated to weigh less than 40 kg who required

> airway management;

> 820 were available for follow-up. INTERVENTIONS:

Patients

> were assigned to receive either BVM (odd days; n =

410) or

> BVM followed by ETI (even days; n = 420). MAIN OUTCOME

> MEASURES: Survival to hospital discharge and neurological status at

> discharge from an acute care hospital compared by treatment group.

> RESULTS: There was no significant

> difference in survival between the BVM group (123/404

> [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95%

> confidence interval [CI], 0.61-1.11) or in the rate of achieving a

> good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%])

> (OR, 0.87; 95% CI, 0.62-1.22).

> CONCLUSION: These results indicate that the addition of

> out-of-hospital ETI to a paramedic scope of practice that already

> includes BVM did not improve survival or neurological outcome of

> pediatric patients treated in an urban EMS system.

>

> Publication Types:

> Clinical Trial

> Controlled Clinical Trial

>

> +++++++++++++++++++++++++++++++++

> Semin Pediatr Surg. 2001 Feb;10(1):3-6. Related Articles, Links

>

> Prehospital endotracheal intubation for severe head injury in

> children: a reappraisal.

>

> A, DiScala C, Foltin G, Tunik M, Markenson D, Welborn C.

>

> Division of Pediatric Surgery, Columbia University College of

> Physicians & amp; Surgeons, Harlem Hospital Center, 506 Lenox Ave,

> 10037 New York, NY, USA.

>

> Controversy exists regarding the efficacy of prehospital assisted

> ventilation by endotracheal intubation (ETI) versus bag-valve-mask

> (BVM) in serious pediatric head injury. The National Pediatric Trauma

> Registry (NPTR-3) data set was analyzed to examine this question.

> NPTR-3 (n = 31,464) was queried regarding the demographics, injury

> mechanism, injury severity, prehospital interventions, transport

> mode, mortality rate, injury complications, procedure and equipment

> failure or complications, and functional outcome of seriously

> head-injured patients (n =

> 578) with comparable injury mechanisms and injury severity

> who received endotracheal intubation (ETI) (n = 479;

83%)

> versus those who received BVM (n = 99; 17%). Mortality rate was

> virtually identical between the 2 groups (ETI = 48%, BVM = 48%),

> although children receiving ETI were significantly older (P < .01),

> more often transported by

> helicopter (P < .01), and more often received

intravenous

> fluid in the field (P < .05). However, injury complications affecting

> nearly every body system or organ (except kidney, gut, and skin)

> occurred less often in

> children receiving ETI (ETI = 58%, BVM = 71%, P <

05).

> Procedure and equipment failure or complications, and functional

> outcome, were similar between the 2 groups.

> Prehospital endotracheal intubation appears to offer no

> demonstrable survival or functional advantage when compared with

> prehospital bag-valve-mask for prehospital assisted ventilation in

> serious pediatric head injury.

> Injury complications appear to occur somewhat less often among

> patients intubated in the field.

>

> +++++++++++++++++++++++++++++++++++

> J Emerg Med. 2002 Jan;22(1):71-4. Related Articles, Links

>

> Out-of-hospital pediatric intubation by paramedics: the San Diego

> experience.

>

> Vilke GM, Steen PJ, AM, Chan TC.

>

> The Department of Emergency Medicine, University of California, San

> Diego Medical Center, San Diego, California 92103, USA.

>

> To evaluate pediatric endotracheal intubations by our paramedics, we

> performed a retrospective review of a prehospital computer database,

> quality assurance reviews, and prehospital run sheets for all patients

> under 15 years of age who had an endotracheal tube (ETT) placed.

> During the 4.5-year study period, 324 pediatric patients had

> intubation attempts by field paramedics, of which 264

> (82%) were successful and three were reported esophageal and

> unrecognized by the paramedic. Two of these esophageal placements were

> noted on arrival at the hospital, and one upon turn-over of patient

> care to a nurse of an aeromedical service. All three intubations were

> deemed

> esophageal with direct laryngoscopy, and the patients

had

> been in cardiopulmonary arrest status prior to the intubation. Of the

> 264 patients who had ETT placed, 99% were endotracheal, while only 1%

> were unrecognized esophageal. We conclude that pediatric endotracheal

> intubation by out-of-hospital paramedics in an established EMS system

> has a low occurrence of unrecognized esophageal placements.

>

> ++++++++++++++++++++++++++++++++++++

>

> Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6. Related Articles, Links

>

> Endotracheal intubation in a rural EMS state: procedure utilization

> and impact of skills maintenance guidelines.

>

> Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE.

>

> Department of Emergency Medicine, Maine Medical Center,

> Portland, Maine 04102, USA. burtoj@...

>

> OBJECTIVE: Recent American Heart Association (AHA) guidelines have

> suggested that advanced life support (ALS) providers should have

> " regular field experience, " defined as six to 12 intubations/year, as

> a prerequisite to patient endotracheal intubation (EI). The authors

> sought

> to assess the impact of this guideline on rural

emergency

> medical services (EMS) practice. METHODS: Statewide EMS records were

> reviewed for the calendar years 1997-2001.

> Data reviewed included the number of providers eligible to perform ALS

> skills (including EI), number of procedures performed per year by EMS

> provider, patient age, gender,

> and prehospital diagnosis. The institutional review

board

> approved the study. RESULTS: During the study period, a total of

> 957,836 patient encounters occurred with an average of 1,352 ALS

> providers annually eligible to perform EI. In the five-year period,

> there were 5,615 total EI attempts with a range of 37%-42% of eligible

> providers annually performing EI. A mean of 18 providers per year with

> a range of 1.8%-0.8% of EI-eligible

> providers annually attempted EI in more than five

> patients. One hundred thirty-seven pediatric EI

encounters

> occurred during the five-year period with an annual range of 1.4%-2.7%

> of eligible providers attempting pediatric EI. During the five-year

> investigation, EI success rate was reported as 84% by providers with

> fewer than five annual intubation encounters and 86% by providers with

> more than five encounters. CONCLUSION: Rural EMS

providers

> rarely use EI skills, particularly in pediatric patients.

> If recent AHA intubation guidelines are to be followed in rural EMS

> settings, a small number of EMS providers will meet minimum EI

> utilization requirements.

>

> Publication Types:

> Evaluation Studies

>

> +++++++++++++++++++++++++++++++++++

> J Trauma. 2003 Mar;54(3):444-53. Related Articles, Links

>

> The effect of paramedic rapid sequence intubation on outcome in

> patients with severe traumatic brain injury.

>

> DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen

> P.

>

> Department of Emergency Medicine, UC San Diego, CA 92103-8676, USA.

>

> OBJECTIVE: To evaluate the effect of paramedic rapid sequence

> intubation (RSI) on outcome in patients with

> severe traumatic brain injury. METHODS: Adult major

trauma

> victims were prospectively enrolled over two years using the following

> inclusion criteria: Glasgow Coma Scale (GCS) 3-8, suspected head

> injury by mechanism or physical examination, transport time > 10, "

> and inability to intubate without RSI. Midazolam and succinylcholine

> were administered before laryngoscopy; rocuronium was given after tube

> placement was confirmed using physical

> examination, capnometry, syringe aspiration, and pulse oximetry. The

> Combitube was used as a salvage airway device. For th

T.A. Dinerman EMTP EMSI EIEIO

October 13, 2004

Thanks, Doc.....

My wife, the " Best Little Basic In Texas " , keeps telling

me that I lost 50 IQ points and forgot all my Basic skills

when I got my Red Patch......

It seems that the studies are all agreeing on at least one

fact....the great majority of our patients do better with

agressivly applied " Basic " skills.....

Thanks again.....

TD

> It appears that those with head injuries do worse with

> prehospital intubation. There is no need to hyperventilate

> them--just ventilate and oxygenate.

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

October 13, 2004

These studies do not represent the masses, they are isolated to specific regions

and agencies. Maybe instead of trying to change the world they should focus on

improving thier own system. You know the old saying: " He who lives is glass

houses should not cast stones "

Lee

[EMS_Research] Re: More Problems with Pedi

>> I agree that the routine intubation of Pedi's in respiratory

failure does not improve outcome over BVM, but should we remove

this technique from the Paramedics " Bag of Tricks " due to it's

overuse in certain circumstances? >>

No, we shouldn't remove it because of its overuse. We should remove

it because it is ineffective and possibly dangerous. Dr. Gausche-

Hill's study from LA not only found no difference in outcome, but a

significant number of unrecognized esophageal placements. (I don't

have the study in front of me, but I think it was in the

neighborhood of 20-25% unrecognized misplacements.) BTW, her study

is not the only one to come to the same conclusion.

Consider this scenario. Your child is critically injured and is

being treated in an emergency room. The physician comes to you for

permission to perform an emergency procedure. He informs you that

if he performs the procedure, it will provide no survival benefit

for your child but there is a 20-25% chance it will create a

situation from which your child could not possibly survive.

Would you give consent for this procedure to be performed?

Thank you for your time,

Kenny Navarro

October 13, 2004

These studies do not represent the masses, they are isolated to specific regions

and agencies. Maybe instead of trying to change the world they should focus on

improving thier own system. You know the old saying: " He who lives is glass

houses should not cast stones "

Lee

[EMS_Research] Re: More Problems with Pedi

>> I agree that the routine intubation of Pedi's in respiratory

failure does not improve outcome over BVM, but should we remove

this technique from the Paramedics " Bag of Tricks " due to it's

overuse in certain circumstances? >>

No, we shouldn't remove it because of its overuse. We should remove

it because it is ineffective and possibly dangerous. Dr. Gausche-

Hill's study from LA not only found no difference in outcome, but a

significant number of unrecognized esophageal placements. (I don't

have the study in front of me, but I think it was in the

neighborhood of 20-25% unrecognized misplacements.) BTW, her study

is not the only one to come to the same conclusion.

Consider this scenario. Your child is critically injured and is

being treated in an emergency room. The physician comes to you for

permission to perform an emergency procedure. He informs you that

if he performs the procedure, it will provide no survival benefit

for your child but there is a 20-25% chance it will create a

situation from which your child could not possibly survive.

Would you give consent for this procedure to be performed?

Thank you for your time,

Kenny Navarro

October 13, 2004

These studies do not represent the masses, they are isolated to specific regions

and agencies. Maybe instead of trying to change the world they should focus on

improving thier own system. You know the old saying: " He who lives is glass

houses should not cast stones "

Lee

[EMS_Research] Re: More Problems with Pedi

>> I agree that the routine intubation of Pedi's in respiratory

failure does not improve outcome over BVM, but should we remove

this technique from the Paramedics " Bag of Tricks " due to it's

overuse in certain circumstances? >>

No, we shouldn't remove it because of its overuse. We should remove

it because it is ineffective and possibly dangerous. Dr. Gausche-

Hill's study from LA not only found no difference in outcome, but a

significant number of unrecognized esophageal placements. (I don't

have the study in front of me, but I think it was in the

neighborhood of 20-25% unrecognized misplacements.) BTW, her study

is not the only one to come to the same conclusion.

Consider this scenario. Your child is critically injured and is

being treated in an emergency room. The physician comes to you for

permission to perform an emergency procedure. He informs you that

if he performs the procedure, it will provide no survival benefit

for your child but there is a 20-25% chance it will create a

situation from which your child could not possibly survive.

Would you give consent for this procedure to be performed?

Thank you for your time,

Kenny Navarro

October 13, 2004

You're kidding, right? Los Angeles is an " isolated region? " I just

Googled pediatric intubation studies and found references to what Mr.

Navarro refers from the National Institute of Health, Firechief

magazine, the NEJM, Pediatric Emergency Medicine Reports, I could go on,

but I think (hope!) you get the point.

Rick LaChance

>>> mrems@... 10/13/2004 9:51:53 AM >>>

These studies do not represent the masses, they are isolated to

specific regions and agencies. Maybe instead of trying to change the

world they should focus on improving thier own system. You know the old

saying: " He who lives is glass houses should not cast stones "

Lee

[EMS_Research] Re: More Problems with Pedi

>> I agree that the routine intubation of Pedi's in respiratory

failure does not improve outcome over BVM, but should we remove

this technique from the Paramedics " Bag of Tricks " due to it's

overuse in certain circumstances? >>

No, we shouldn't remove it because of its overuse. We should remove

it because it is ineffective and possibly dangerous. Dr. Gausche-

Hill's study from LA not only found no difference in outcome, but a

significant number of unrecognized esophageal placements. (I don't

have the study in front of me, but I think it was in the

neighborhood of 20-25% unrecognized misplacements.) BTW, her study

is not the only one to come to the same conclusion.

Consider this scenario. Your child is critically injured and is

being treated in an emergency room. The physician comes to you for

permission to perform an emergency procedure. He informs you that

if he performs the procedure, it will provide no survival benefit

for your child but there is a 20-25% chance it will create a

situation from which your child could not possibly survive.

Would you give consent for this procedure to be performed?

Thank you for your time,

Kenny Navarro

October 13, 2004

It seems that there are multiple issues here. First, are the studies

showing no benefit from correctly placed ET tubes? That is fundamentally

different from finding that there are negative consequences from incorrectly

placed tubes (duh!), and I am curious if the esophageal intubations are

dragging the numbers down with regard to benefit. If there is no benefit in

intubating children, we should seriously look at the emphasis we place on

doing so in the field, whereas if the argument is that there is some benefit

but we just aren't very good at doing it, we need to improve training in

this area.

It is no surprise to me that the complication rate is so high. Students

just don't have the opportunity to practice on pediatric patients in the OR

or ER, and you don't get that much experience with pediatric patients in

general when working in the field. Add this to the fact that we sometimes

work in an environment that is not as favorable as the hospital, and you can

understand how things are not working out very well.

The weight of the evidence seems to suggest that pediatric intubation is

overused, although I think the topic needs further study before we can

definitely conclude one way or the other. In the end, however, if the

studies show no benefit and possible detriment, we need to do what is best

for our patients.

-

PS Did any of the services in these studies use capnography?

[EMS_Research] Re: More Problems with Pedi

It stands to reason that better education and preparation in pediatric

intubation would overcome this 20-25% misplacement problem, rather than

remove the procedure altogether. What about gastric distention from

using the BVM? Decreased pulmonary capacity, massive potential for

aspiration, removal of a medication administration route(LEAN),. Just

use an NG/OG tube? What about NG/OG misplacement? I'd rather have

better education and preparation in pediatric intubation.

-mikey

>>> kenneth.navarro@... 10/13/04 9:37:12 AM >>>

>> I agree that the routine intubation of Pedi's in respiratory

failure does not improve outcome over BVM, but should we remove

this technique from the Paramedics " Bag of Tricks " due to it's

overuse in certain circumstances? >>

No, we shouldn't remove it because of its overuse. We should remove

it because it is ineffective and possibly dangerous. Dr. Gausche-

Hill's study from LA not only found no difference in outcome, but a

significant number of unrecognized esophageal placements. (I don't

have the study in front of me, but I think it was in the

neighborhood of 20-25% unrecognized misplacements.) BTW, her study

is not the only one to come to the same conclusion.

Consider this scenario. Your child is critically injured and is

being treated in an emergency room. The physician comes to you for

permission to perform an emergency procedure. He informs you that

if he performs the procedure, it will provide no survival benefit

for your child but there is a 20-25% chance it will create a

situation from which your child could not possibly survive.

Would you give consent for this procedure to be performed?

Thank you for your time,

Kenny Navarro

October 13, 2004