List Archives

Wed, 27 Mar 2002 15:12:04 +1100

This is a multi-part message in MIME format.

--------------InterScan_NT_MIME_Boundary
Content-Type: text/plain;
	charset="iso-8859-1"

I think Dr Cottingham may be confusing what he feels he is capable of, with
what the system is actually trained to do and capable of. 
I would be very worried about making statements such as: 'I have gone on >
record before as stating that I would act for the prosecution in any > case
where soiling of the lower airway occurred after insertion of a > laryngeal
mask after trauma.'and "LMA is not a safe way of securing the airway. How do
you wish to contest that statement?"
The whole benefit of prehospital intubation in trauma patients is unclear.
There is only one "decent" trial in children that shows no difference in
outcome when compared with BVM ventilation. This study was associated with
2% rate of unrecognised oesphageal intubation, 8% dislodgement and 18%
bronchial mainstem intubation. (Gausche M. Effect of out of hospital
paediatric endotracheal intubation on survival and neurological outcome. A
controlled clinical trial. JAMA 2000,283:783-790.)
The success rates for out of hospital intubation success ranges from 49-99%
in the published studies and is dependent on the use of drugs to facilitate
intubation. The rates of misplaced tracheal tubes may be as high as 25%.
Katz SH. Misplaced endotracheal tubes by paramedics in an urban emergency
medical services system. Annals of Emergency Medicine. 37(1):32-7, 2001 Jan.
Hands up all those that think this is acceptable.

How many EMS are allowing the use of sedatives and neuromuscular blockers in
the pre-hospital setting? There are obviously the training and skill
retention issues that go along with this. Just what is being taught for
intubating a unconscious patient in extremis in the prehospital setting
where you can't get into a position to do laryngoscopy and the airway is
filling with blood from the facial fractures?

The LMA is a safe airway device associated with 0.5-0.009% incidence of (not
necessarily clinically significant) airway soiling during anaesthesia.
(Brimacombe J The incidence of aspiration associated with the laryngeal
mask: a meta-analysis. J Clin Anaesthesia 1995:7:297-305. Verghese C. Survey
of laryngeal mask airway usage in 11,910 patients: safety and efficacy for
conventional and nonconventional usage. Anaesthesia and Analgesia
1996;82:129-33.). 
Controversially: It may well be appropriate in a variety of prehospital
situations. 
More controversially: It may be more appropriate than what is going on in
the prehospital setting at the moment. 
Yes, I know there will be some Europeans replying extolling the virtues of
prehospital physicians but that is a rarity in the world as a whole.

In the can't/unable to intubate trauma situation I would be more concerned
about the risk of aspiration from above the larynx (blood/debris) and the
fact that BVM is probably not good with that. Lockey DJ. Aspiration in
severe trauma: a prospective study. Anaesthesia. 54(11):1097-8, 1999 Nov. 

Your turn.

Mike

Michael Parr
Intensive Care Unit
Liverpool Hospital
Sydney, Australia
Michael.Parr@swsahs.nsw.gov.au

	-----Original Message-----
	From:	rowley@rowleys-host.compulink.co.uk
[SMTP:rowley@rowleys-host.compulink.co.uk]
	Sent:	Tuesday, 26 March 2002 19:39
	To:	trauma-list@trauma.org
	Cc:	rowley@cix.co.uk
	Subject:	RE: LMA

	I think Dr Cottingham may be confusing what he feels he is capable
of, with what the system is actually trained to do and capable of. I would
be very worried about making statements such as:
	 'I have gone on > record before as stating that I would act for the
prosecution in any 
	> case where soiling of the lower airway occurred after insertion of
a > laryngeal mask after trauma.'
	and "LMA is not a safe way of securing the airway. How do you wish
to contest that statement?"
	The whole benefit of prehospital intubation in trauma patients is
unclear. There is only one "decent" trial in children that shows no
difference in outcome when compared with BVM ventilation. This study was
associated with 2% rate of unrecognised oesphageal intubation, 8%
dislodgement and 18% bronchial mainstem intubation. (Gausche M. Effect of
out of hospital paediatric endotracheal intubation on survival and
neurological outcome. A controlled clinical trial. JAMA 2000,283:783-790.)
	The success rates for out of hospital intubation success ranges from
49-99% in the published studies and is dependent on the use of drugs to
facilitate intubation. The rates of misplaced tracheal tubes may be as high
as 25%. Katz SH. Misplaced endotracheal tubes by paramedics in an urban
emergency medical services system. Annals of Emergency Medicine. 37(1):32-7,
2001 Jan. 

	How many EMS are allowing the use of sedatives and neuromuscular
blockers in the pre-hospital setting? There are obviously the training and
skill retention issues that go along with this. Just how do you intubate a
unconscious patient in extremis in the prehospital setting where you can't
get into a position to do laryngoscopy and the airway is filling with blood
from the facial fractures?

	The LMA is a safe airway device associated with 0.5-0.009% incidence
of (not necessarily clinically significant) airway soiling during
anaesthesia. (Brimacombe J The incidence of aspiration associated with the
laryngeal mask: a meta-analysis. J Clin Anaesthesia 1995:7:297-305. Verghese
C. Survey of laryngeal mask airway usage in 11,910 patients: safety and
efficacy for conventional and nonconventional usage. Anaesthesia and
Analgesia 1996;82:129-33.). It may well be appropriate in a variety of
prehospital situations

	In the can't/unable to intubate situation I would be more concerned
about the risk of aspiration from above the larynx (blood/debris) and the
fact that BVM is probably not good with that. Lockey DJ. Aspiration in
severe trauma: a prospective study. Anaesthesia. 54(11):1097-8, 1999 Nov. 

	Your turn.

	Mike

--------------InterScan_NT_MIME_Boundary
Content-Type: text/plain;
	name="InterScan_Disclaimer.txt"
Content-Transfer-Encoding: 7bit
Content-Disposition: attachment;
	filename="InterScan_Disclaimer.txt"

                        *****  IMPORTANT NOTICE  *****

The opinions and views expressed in this e-mail are those of the sender 
and may not necessarily represent the management of the South Western 
Sydney Area Health Service. The information contained within this e-mail 
is intended for the named recipients only and it may contain confidential 
and/or privileged information. If you have received this message in error, 
you must not copy, duplicate, forward, print or otherwise distribute any 
information contained herein, but must ensure that this e-mail is permanently 
deleted and advise the sender immediately.

--------------InterScan_NT_MIME_Boundary--

List Archives

For your convenience, find the Trauma List Archive Below

LMA