Maintaining Patient Airways

2612 words (10 pages) Essay in Nursing

24/05/17 Nursing Reference this

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Securing and maintain a patent airway reserves the highest priority when caring for critical ill or injured patient. When airway intervention is required it should be performed in an expedient and organised fashion by an experienced individual with the goal of providing a definitive airway safely, minimizing any possible complications (Braude and Richards, 2007). The decision to place a definitive airway is based on clinical decision and the understanding that a stable patient may deteriorate rapidly, requiring frequent reassessment of their airway, ventilatory and neurologic status, as well as vital signs. A definitive airway is meant to represent an endotracheal tube (ETT) that is placed in the trachea, passing through the vocal cords with a balloon located distally, serves to protect against aspiration when inflated (Stept and Safar, 1970).

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Rapid sequence intubation (RSI) has the same goal in order to be successfully which takes experience, a thorough understanding of its indications, contraindications and limitations, with working knowledge of the physiology and pharmacological agents used (Pousman, 2000: 03). In the following research assignment the following key words will be discussed: brief history of RSI, RSI technique, indication of RSI, and literature review of RSI performed by paramedics and author suggestion.

Methodology

In the research of this assignment a number of resources had been utilized. These includes the use of internet data-bases specifically the science direct website, American Heart association website, up-to-date website, trauma organisation website, ispub website and Google Scholar search with the following key phrases being employed, history of RSI, definitions of RSI, indications of RSI, and the following key words under Rapid Sequence Intubation: literature review, pre-hospital, and paramedic performing .

Journal articles concerning pre-hospital RSI in Emergency Medicine Journal, Annals of Emergency Medicine, Prehospital and Disaster Medicine, Critical Care Journal, Canadian Journal of Anaesthesia and Prehospital Emergency Care Journal had been consulted through getting them on the Internet. The following reference books have been consulted for the help of this research, Mosby’s paramedic textbook, Emergency Medicine – just the fact, manual of Emergency Airway Management.

The selection of references of this literature review was based on quality, appropriateness, insight and depth of scientific knowledge relevant to the topic. Meanwhile, rejection of reference was due to antiquity, superficial, irrelevance and inappropriate to the reviewed topic. The author found it more critical, challenging and further research being more essential. Scientific evidence was derived from aggregated researches literature, open presentation and other consensus oriented activities. For the purpose of literature aggregation, potentially relevant clinical studies were identified via electronics through different journals.

Discussion

Airway management is fundamental in the care of critically ill and injured patients. Without an adequate supply of oxygen, vital organs such as the brain and heart begin to die. Management of the airway encompasses a spectrum of techniques, including non-invasive methods such as bag-valve-mask (BVM) ventilation, and more advanced methods such as endotracheal intubation (ETI). ETI provides a direct channel to the lungs to facilitate delivery of oxygen and ensure adequate ventilation. In addition, the endotracheal tube has an inflatable cuff designed to prevent aspiration into the lungs (Walls, 2000).

The ability of paramedics to perform ETI has been well demonstrated since 1975, with reported success rates ranging from 88% to 98%. These studies include patients in a vast array of clinical situations and use of RSI was introduced to the pre-hospital environment in hope of improving patient outcome by enhancing early definitive airway management (Wayne and Friedland, 1999).

RSI quite rapidly became the accepted standard for induction of anaesthesia in patients. Over the past two decades it has increasingly achieved a similar status for emergency intubations in other areas such as in ICU and by medical emergency teams; and in the emergency department, especially for trauma patients (Wang and Yealy, 2002). The use of RSI was pioneered in the prehospital environment by hospital based air medical teams, initially predominantly physician led but later in the USA often by (nurse based) non-physician teams. RSI has subsequently been introduced into paramedic practice in some jurisdictions (Munford et al, 2005).

Taryle et al (1975) suggested more than 20 years ago that the intubation of patients in the emergency department (ED) setting could be assisted by the use of techniques and drugs used in the operating room setting. Rapid-sequence induction was a technique first described by Stept and Safar (1970) in the anaesthesia literature as a method for minimizing the risk of regurgitation and aspiration during the induction of a patient with a full stomach; this method prescribed 15 specific steps for rapid induction and intubation in the operating room setting.

3.1. History of RSI

It is not clear when RSI was first used in the prehospital setting. Subjective reports of prehospital RSI date back to 1972 in Seattle, Washington. The first formal report of prehospital RSI in 1998, describing 95 RSIs performed by paramedics in Thurston County, Washington (Wang, O’Connor, and Domeier, 2001). Since then, at least 25 studies have described the use of prehospital RSI by either ground or air medical emergency medical services. A 1997 survey indicated that at least 29 states permitted the use of neuromuscular blocking agents by EMS units. That number is much higher in 2006. Today, RSI is used as a technique for rapidly gaining control of the airway to facilitate rapid placement of an endotracheal tube and is considered a standard part of emergency medicine.

Since its introduction in the late 1970s, there has been a great deal of controversy over RSI within the medical community. This controversy stems partly from individuals who are not familiar with their EMS systems competence and feel that this task cannot be safely performed by a non-physician. Numerous studies, however, have proven that, in experienced hands, RSI can be safely performed in the pre-hospital setting (Pousmam, 2000:04).

Rapid sequence induction (RSI) is the use of pharmacologic agents to aid in establishing a definitive airway. More than 90% of in-hospital intubations use RSI, with the other 10% being “crash intubations” or those where the obtunded patient does not require initial sedation or neuromuscular blocking agents (NMBAs). It is intended for patients who are considered at risk of aspirating stomach contents, the so-called “full-stomach” patients, as an effort to decrease the potential occurrence of pulmonary aspiration (Wang, O’Connor, and Domeier, 2001).

Some studies have tried to demonstrate that nasal intubation is superior to pharmacology assisted oral intubation. Although nasal intubation may be quicker in some providers’ hands, RSI has a consistently higher initial success rate (Hubble et al, 2010).

The use of rapid-sequence intubation (RSI) in the prehospital setting has now been researched for almost 20 years. Early data pointed toward success, but outcome research released over the last few years has called this into question. Despite this, there has been an increased use of the procedure by paramedic.

Prehospital RSI has many theoretical benefits, including improved oxygenation and ventilation, aspiration protection, protection of the decompensating airway and spinal protection through sedation and paralysis. The procedure also has the potential of decreasing failed endotracheal intubations in certain situations.

RSI Technique

In non-emergent situations, the patient is normally given an induction agent, which rapidly produces unconsciousness and apnea. At this point, there is a period of assisted ventilation and oxygenation via bag-valve-mask ventilation to establish the presence of a patent airway, as well as to determine the ability to oxygenate. This is performed before administering the neuromuscular blocking agent. Once the presence of an airway is established and ventilation can be easily performed, the neuromuscular blocking agent is given and tracheal intubation follows shortly after.

The difference in RSI performance is exclusion of assisted ventilation once the patient is induced. The induction agent is immediately followed by administration of the paralytic agent, thus the name “rapid sequence induction.”

Literature review of RSI by Paramedic

Ochs et al (2002) describe their experience implementing a paramedic rapid sequence intubation program in a consortium of ground San Diego emergency medical services (EMS). They limited the technique to patients with head injuries, defined specific clinical parameters for executing the procedure, and observed an RSI success rate of 84.2%. Their conclusion is that paramedics in this setting can successfully use neuromuscular blocking agents to facilitate endotracheal intubation of patients with head injuries while others describe out-of-hospital RSI success rates considerably higher than 90%, and several systems achieved greater than 95% success. Wayne and Friedland (1999) offered data on 1,657 RSI’s performed by a ground EMS service over a 20-year period, reporting a success rate of 95.5%.

The Journal of Trauma study demonstrated that prehospital personnel can perform RSI safely and effectively in patients with traumatic brain injury. The study suggests that certain criteria should be met to reduce complications. These criteria include ongoing training in a select group of individuals to maximize experience along with close monitoring and supervision.

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Despite controversy regarding the safety of RSI in the hands of prehospital providers, it has been shown that when proper training with routine assessment of skills and close medical supervision/co-operation, this can be accomplished with great success.

Of 114 enrolled patients, 96 (84.2%) underwent successful endotracheal intubation, and 17 (14.9%) underwent Combitube intubation, with only 1 (0.9%) airway failure. There were no unrecognized oesophageal intubations. On arrival at the trauma centre, median oxygen saturation was 99%, mean arrival PO2 was 30.7 mm Hg, and mean arrival PCO2 was 35.8 mm Hg. Total out-of-hospital times were higher when RSI was performed on scene (26 versus 13 minutes). Their conclusion on the study is that, paramedics can use RSI protocols that include neuromuscular blocking and sedative agents to facilitate intubation of patients with head injuries (Cudnik, Newgard and Daya, 2010).

Two studies have paved the way for the outlook on RSI. Studies done in San Diego began to indicate that prehospital RSI was actually increasing the mortality rate of the patients that it was performed on, while a study done in Seattle showed directly opposite results and what consensus drawn from these results?

Wang et al recently identified a set of factors that were associated with ETI failure in the prehospital setting. Factors reported that could theoretically be corrected by RSI included trismus, inability to pass the endotracheal tube through the vocal cords and intact gag reflex.

RSI has consistently been reported to have high success rates when done by aero medical paramedics. Reported success of ground paramedic has not had the same consistency. The reason for the disparity is unclear. The level of experience may be more variable with ground than helicopter paramedic, and training provided to the paramedics may explain part of this disparity, as well. The paramedics in the Wayne et al study appeared to have more training than did paramedics in the San Diego RSI Trial. While the studies are not directly comparable because of methodology, this represents a plausible explanation. Finally, the medications and doses used across studies have not been consistent.

Author Suggestions

There have been attempt to determine the reasons for the poor out comes associated with RSI in ground EMS service. These explanation have included: increase on scene time (average 15 minutes in one day), lack of adequate training of the paramedics, in appropriate hyperventilation and non-recognition of hypoxia during induction, which all of this factors can be minimise or eliminated by good education of RSI and effective training which will correct the poor outcomes.

However, given the intubation success rate documented in the Ochs et al trial, we must ask whether this study is in fact an illustration of what happens when out-of-hospital RSI is applied in this multisystem manner. Out-of-hospital RSI involves not only a discrete procedure with a set of drugs, but also a comprehensive commitment to closely monitor and improve all aspects of clinical airway care. Where and how we choose to introduce the technique can be important determinants of the outcomes.

Despite recent studies showing the lack of efficacy of RSI in the pre-hospital setting, a distinct pattern of improved out come had emerged in the sub-population of those patients where air medical transport had been used. What is clear to us in the present moment is that paramedic need intense quality oversight and maintenance of competency programs and high quality airway management training which are features that will continue yield better success rates and improved outcomes.

Numerous studies have been done over the years, obviously sponsored by both ‘pro’ and ‘anti’ RSI groups. Each of those studies supports their specific agenda. Those who read and review those studies often rely on the studies that further support their specific agenda.

Our opinion, and the way we view RSI is either supported or dissuaded by studies, or by untrustworthy evidence. EMS should be, and is becoming, a scientific based process. RSI has stood the test of the studies, as long as it is done correctly, and for all the right reasons there will be good patient outcome and decrease mortality.

The Journal of Trauma study demonstrated that prehospital personnel can perform RSI safely and effectively in patients with traumatic brain injury. The study suggests that certain criteria should be met to reduce complications. These criteria include ongoing training in a select group of individuals to maximize experience along with close monitoring and supervision.

Despite controversy regarding the safety of RSI in the hands of prehospital providers, it has been shown that when proper training with routine assessment of skills and close medical supervision/co-operation, this can be accomplished with great success.

The Professional Board for Emergency Care at the Health Professions Council of South Africa (HPCSA) has approved pre-hospital rapid sequence intubation (RSI) as part of the scope of practice for registered emergency care practitioners (ECPs) which they have seen that the benefit of the patient was high. Pre-hospital RSI may not be implementable in all emergency medical services in South Africa because of lack of resources. Apart from personnel requirements, services wishing to implement pre-hospital RSI must be properly prepared, including providing ECPs with the prescribed minimum training, systems requirements and robust clinical governance (Stein et al, 2011: 163).

Other aspects of outcome data need to be researched, as well. The possibility that experienced paramedics may have better outcomes with the procedure needs to be more fully explored. Outcome data for prehospital RSI and how it relates to other patient populations, such as undifferentiated trauma and medical respiratory distress, needs to be evaluated. Finally, outcome data in regard to RSI and transport time may help define a population that benefits from the procedure. So RSI does not yield poor outcome and does not increase mortality of patient pre-hospital. Finally give the right equipment, resources, proper training and monitoring together with personnel the outcome will be better compare to some studies done in early years which will results in fewer mortality rates.

Conclusion

The use of RSI is intended to allow rapid, safe airway management and protection while minimizing periods of hypoxia. Protection against aspiration of gastric contents is crucial in performing this technique, and it is prudent to understand the patients at risk for such a complication. This technique has been used extensively in operating rooms and is also gaining popularity in the emergency department.

Rapid sequence induction tracheal intubation is the technique of choice in the vast majority of patients, but requires a combination of knowledge; skills and judgement that are best achieved through structured training and supervised practice. All emergency airway practitioners must work within their scope of competence, using techniques, drugs and equipment with which they are familiar them.

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