Je suis sur que nos super paramedics sont mieux entraines que nos voisins du
sud... :)
Mais avec cette etdue, il y a de quoi nous pousser encore plus a ne pas hesiter
a verifier le A et B lors d'une arrivee d'un patient intubate
Summary
and Comment
Adult Prehospital Intubation: More Harm Than Good?One
quarter of intubated patients had unrecognized, misplaced endotracheal
tubes in a study from the New York City emergency medical
system.
Recent pediatric studies in emergency medical
systems with short transport times suggest that prehospital intubation
provides no benefit or is even potentially harmful, compared with
ventilation alone. In a prospective observational study, researchers
assessed the frequency of unrecognized esophageal intubation in 132
consecutive adult patients who were transported to two New York City
emergency departments and had been intubated in the field. Emergency
physicians confirmed tube placement by direct visualization (71%),
end-tidal carbon dioxide detection (39%), or both. Tubes were misplaced in
32 patients (24%), with 20 tubes in the right mainstem bronchus, 11 in the
esophagus, and 1 in the hypopharynx. Only one patient with a prehospital
esophageal intubation survived to hospital discharge. Information was not
available on the training and experience of the paramedics who performed
all prehospital intubations.
The researchers assessed reasons for deferred intubation in a separate
group of 60 consecutive patients who were intubated within 10 minutes after
arrival at the same hospitals. Prehospital intubation was not attempted in
52% and was unsuccessful in 22%. The most common reasons for not attempting
prehospital intubation were short transport time and suspected difficult
airway. The authors call for controlled trials to assess whether
prehospital intubation of adult patients improves outcomes.
Comment: Adult prehospital endotracheal intubation is yet another
example of a protocol that was implemented without prior scientific
validation of outcomes benefit. Now that this procedure is standard care,
controlled trials would be difficult to design and might face challenges
from research ethics boards. However, the high rate of tube misplacement
found in this study — consistent with rates reported in other systems
— is unacceptable. The key prehospital intervention is oxygenation,
not necessarily intubation; other airway management methods, such as use of
laryngeal mask airways, may be preferable to intubation. Prehospital
intubation requires mandatory confirmation of proper tube placement by
end-tidal carbon dioxide monitoring, which often was not done in this
study. EPs must immediately confirm proper tube placement for all patients
who have been intubated in the field.
— Kristi
L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine June 15,
2007
Citation(s):
Wirtz DD
et al. Unrecognized misplacement of endotracheal tubes by ground
prehospital providers.
Prehosp Emerg Care
2007 Apr-Jun; 11:213-8.
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