Improving door to balloon times in STEMI

Nationwide Improvement of Door-to-Balloon Times in Patients With Acute ST-Segment Elevation Myocardial Infarction Requiring Primary Percutaneous Coronary Intervention With Out-of-Hospital 12-Lead ECG Recording and Transmission

Annals of Emergency Medicine: Volume 61, Issue 3 , Pages 339-347, March 2013

Reducing door-to-balloon times for acute ST-segment elevation myocardial infarction (STEMI) patients has been shown to improve long-term survival. The authors aimed to reduce door-to-balloon time for STEMI patients requiring primary percutaneous coronary intervention by adoption of out-of-hospital 12-lead ECG transmission by Singapore’s national ambulance service.

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Methods: This was a nationwide, before-after study of STEMI patients who presented to the emergency departments (ED) and required percutaneous coronary intervention. In the before phase, chest pain patients received 12-lead ECGs in the ED. In the after phase, 12-lead ECGs were performed by ambulance crews and transmitted from the field to the ED. Patients whose ECG showed greater than or equal to 2 mm ST-segment elevation in anterior or greater than or equal to 1 mm ST-segment elevation in inferior leads for 2 or more contiguous leads and symptom onset of less than 12 hours’ duration were eligible for percutaneous coronary intervention activation before arrival.

Results: ECGs (2,653) were transmitted by the ambulance service; 180 (7%) were suspected STEMI. One hundred twenty-seven patients from the before and 156 from the after phase met inclusion criteria for analysis. Median door-to-balloon time was 75 minutes in the before and 51 minutes in the after phase (median difference=23 minutes; 95% confidence interval 18 to 27 minutes). Median door-to-balloon times were significantly reduced regardless of presentation hours. Overall, there was significant reduction in door-to-activation, door-to-ECG, and door-to–cardiovascular laboratory times. No significant difference was found pertaining to adverse events.

This study describes a nationwide implementation of out-of-hospital ECG transmission resulting in reduced door-to-balloon times, regardless of presentation hours. The authors recommend that out-of-hospital ECG transmission should be adopted as best practice for management of chest pain.

The Airtraq Optical Laryngoscope in HEMS: A Pilot Trial

The Airtraq Optical Laryngoscope in Helicopter Emergency Medical Services: A Pilot Trial

Air Medical Journal: Volume 32, Issue 2 , Pages 88-92, March 2013

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

The objective of this study was to determine the degree of success helicopter emergency medical services personnel have in placing an endotracheal tube using a relatively new device for endotracheal intubation (ETI) known as the Airtraq (AT) Optical Laryngoscope (King Systems Corp, Noblesville, IN), and to determine the frequency with which flight crews had to resort to other means for advanced airway management.

Methods: This prospective, observational pilot trial evaluated the critical care flight team’s ability to perform ETI using the AT as a first-line device in the prehospital setting. Flight crews were instructed to use the AT for any patient needing ETI. Teams completed a 30-minute training session followed by mannequin practice. They documented situations and outcomes: reason for ETI, success in placing the AT, reason for unsuccessful placement, end-tidal carbon dioxide concentration in expired air (ETCO2), and where patients were when they underwent intubation (field, ambulance, aircraft, hospital). Data were abstracted and analysed using JMP software version 7.0 (SAS Institute, Inc, Cary, NC).

Results: Fifty cases involving use of the AT were analysed. Median patient age was 51.5 years (range, 15–90; interquartile range, 36–64.5). Most patients were male (n = 37 [74%]). The primary reasons for intubation were unresponsiveness and altered loss of consciousness (n = 23 [46%]), respiratory distress or apnea (n = 8 [16%]), cardiac arrest (n = 10 [20%]), and combative behaviour (n = 7 [14%]). AT was successful (n = 31[62%]) in 1 to 2 attempts. The primary reason for AT failure was blood or vomit in the airway (n = 8 [42.1%]); 48.1% (n = 25) of patients required a different management mode.

The study found that HEMS crews had difficulty placing successful ET tubes with this device after minimal education with a single regular-sized device. Difficulty was pronounced when blood or vomit was present and obstructing the optical view. The authors believe that further study is needed to evaluate the implementation time, training time required, and possible design advantages of the AT compared with those of traditional emergent airway management techniques. My personal concern is with the statement “minimal education”, I found that after years of using a traditional laryngoscope for intubation it takes a while to change the muscle memory associated with intubation following the move to optical and video laryngoscopes. One of the most effective ways to overcome this is by using the new devices, whether in a clinical environment or simulation laboratory, but for this study the participants received a 30 minute didactic lecture on device function and technique and then manikin practice with a requirement for 2 successful placements.

Supraglottic airway device use as a primary airway during RSI

Supraglottic Airway Device Use as a Primary Airway During Rapid Sequence Intubation

Air Medical Journal: Volume 32, Issue 2 , Pages 93-97, March 2013

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls.

Method: 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO2, ETCO2 at 2 minutes after placement, and complications were also analysed.

Results: 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12–46). Pre- and post-insertion SaO12 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient’s airway was the most frequently reported complication (46%).

The authors found that the success rates with the King LTS-D were not significantly different from historical control ETI data with no major difference in the time to placement when compared with previous reports. On a personal opinion, if using a supraglottic airway device takes the same time to insert and has similar success rates as endotracheal intubation, surely endotracheal intubation should be the first choice option (especially with nearly 50% of patients having vomit in the airway), keeping supraglottic devices  as part of a failed intubation procedure?