Objective: To study the indications, method, success rate and complications of intubation at the Emergency Department of a private, tertiary care hospital in Karachi, Pakistan.Methods: The case series involved 278 patients above 14 years of age who underwent emergency intubation at the Emergency Department of Aga Khan University Hospital, Karachi between 1998 and 2003. Descriptive statistics were used to compare rapid sequence intubation with crash intubation. The level of significance was p\u3c0.05.Results: Of the total 278 intubations performed, 37 (13.3%) had to be left out for incomplete information. The study population remaining for inferential analysis comprised of 241 patients. Of the total 278 patients, 174 (63%) were males. Rapid sequence intubation was the commonest type (n=185, 67%) of intubation and was performed mostly by anaesthetists (n=236, 85%). Cardiogenic pulmonary oedema and head injury were commonly seen in these patients. The success on first attempt of intubation was 98% (n=181) in rapid sequence intubation, and 85% (n=48) in crash intubation. Overall, 15 (5.3%) complications were seen in these intubations.Conclusion: Study showed a satisfactory success rate in both rapid sequence and crash intubations

Ahmad, Humaid

Ejaz, Kiran

Khan, Nadeem Ullah

Khan, Uzma R.

Razzak, Junaid Abdul

Zia, Nukhba

eCommons@AKU

eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanMarch 2013Intubation in emergency department of a tertiarycare hospital in a low-incomeNadeem Ullah KhanAga Khan UniversityUzma R. KhanAga Khan University, uzma.khan@aku.eduKiran EjazAga Khan UniversityHumaid AhmadAga Khan UniversityNukhba ZiaAga Khan UniversitySee next page for additional authorsFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Anesthesiology Commons, and the Emergency Medicine CommonsRecommended CitationKhan, N. U., Khan, U., Ejaz, K., Ahmad, H., Zia, N., Razzak, J. A. (2013). Intubation in emergency department of a tertiary carehospital in a low-income. Journal of Pakistan Medical Association, 63(3), 306-309.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/34AuthorsNadeem Ullah Khan, Uzma R. Khan, Kiran Ejaz, Humaid Ahmad, Nukhba Zia, and Junaid Abdul RazzakThis article is available at eCommons@AKU: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/34IntroductionAirway control and adequate ventilation are paramount tothe management of acutely ill patients and bear significantimpact on the course of their disease. This task, mostlyaccomplished with endotracheal intubation (ETI), enablesdelivery of specific inspired oxygen concentration andinstitution of positive pressure ventilation.1 However, thishighly skilled life-saving procedure involves risksespecially when performed in an emergency situationcompared to performing it in elective conditions of anoperating room.2,3 These differences are due to setting,patient characteristics, method used for intubation andtimely availability of experienced personnel. The risk ofcomplications with intubations has been reported to be14-28% and it increases with the number of attempts aswell as depends on the method of intubation.4Rapid sequence intubation (RSI) and crash intubations aretwo different approaches for ETI in an emergencysituation. Between the two, RSI is more common and saferfor patients presenting to an emergency department(ED).5 Significance of ETI mandates that all physicians withacute care responsibilities, especially emergencyphysicians (EPs), should be competent in its institutionand have the expertise to handle full spectrum of airwayproblems.6 Previously ETI was the domain of ananaesthesiologist and even now in many parts of theworld they are called to other units of the hospitals,including ED, to manage airway problems.With the development of emergency medicine (EM) as arecognised medical specialty, airway management hasbecome an essential skill for EPs.7 Its teaching is amandatory component of training curriculum, and inCanada and the United States, EPs have already takenover this responsibility and deal with the major chunk ofpatients requiring emergency intubation.7-9 The situationis significantly different in England and Wales whereanaesthetists perform the majority of RSI, and EPsperform it in only a few teaching hospitals.10The data for successful intubation and its complication issparse in developing countries. A study from Thailandreported overall success of 99.6% for orotrachealintubation (both RSI and crash intubation) and successfulintubation on first attempt in 79.5% of patients.11Anaesthetists performed most of these intubations.A similar situation exists in Pakistan where few teachinghospitals have qualified EPs and even fewer have EMresidency programmes. In fact, EM is still evolving as aspeciality in the country and there is a need to haveregional baseline data regarding ETI, especially in EDsetting, for future evaluation of training skills of EMresidents and quality assurance practices. The aims of thisstudy were to gather data on the indications, method,J Pak Med Assoc306ORIGINAL ARTICLEIntubation in emergency department of a tertiary care hospital in a low-incomecountryNadeem Ullah Khan, Uzma Rahim Khan, Kiran Ejaz, Humaid Ahmad, Nukhba Zia, Junaid Abdul RazzakAbstractObjective: To study the indications, method, success rate and complications of intubation at the EmergencyDepartment of a private, tertiary care hospital in Karachi, Pakistan. Methods: The case series involved 278 patients above 14 years of age who underwent emergency intubation at theEmergency Department of Aga Khan University Hospital, Karachi between 1998 and 2003. Descriptive statistics wereused to compare rapid sequence intubation with crash intubation. The level of significance was p<0.05.Results: Of the total 278 intubations performed, 37 (13.3%) had to be left out for incomplete information. The studypopulation remaining for inferential analysis comprised of 241 patients. Of the total 278 patients, 174 (63%) weremales. Rapid sequence intubation was the commonest type (n=185, 67%) of intubation and was performed mostlyby anaesthetists (n=236, 85%). Cardiogenic pulmonary oedema and head injury were commonly seen in thesepatients. The success on first attempt of intubation was 98% (n=181) in rapid sequence intubation, and 85% (n=48)in crash intubation. Overall, 15 (5.3%) complications were seen in these intubations. Conclusion: Study showed a satisfactory success rate in both rapid sequence and crash intubations. Keywords: Emergency department, Intubation, Complications, Pakistan. (JPMA 63: 306; 2013)Department of Emergency Medicine, Aga Khan University Hospital, Karachi.Correspondence: Nadeem Ullah Khan. Email: nadeemullah.khan@aku.edusuccess rate and complications of intubation in the ED ofa private, tertiary care teaching hospital and referralcentre in Karachi, Pakistan. Patients and methodsThe case series spanned a period of five years from June1998 to June 2003 and included patients who presentedto the ED of the Aga Khan University Hospital (AKUH). TheEPs included senior medical officers and trained EMfaculty. During the study period, a 24-hour on-call in-house anaesthesia resident was available for any crash callfor intubation. Both EPs and anaesthetists shared theresponsibility of emergency airway management at thehospital.Patients over the age of 14 years, admitted through ED andrequiring intubation were included. The exclusion criteriawas patients below the age of 14 years, patients intubatedbefore arriving in the ED, patients intubated in other unitsof the hospital, patients who were intubated in ED but hadto be shifted out to some other hospital due to non-availability of ventilator, and patients who expired in theED. Cases were selected through a computerised searchbased on the inclusion criteria of the hospital informationmanagement system. RSI was defined as orotrachealintubation in which both neuromuscular blocking agents(NMBA) and sedatives were used to facilitate the process.Crash intubation was defined as orotracheal intubation inwhich no medications were used. A medical graduate used a data-collection tool to obtainthe following information: patients' demographics,underlying conditions for intubation, precipitating factors(both medical and surgical conditions), specific diagnosis,method of intubation (RSI versus crash), number ofattempts required to intubate successfully, team decidingand intubating the patient, medications used, time delaysafter intubation decision, and immediate complications.Given that the mode of data-collection was throughretrospective chart review, information bias was possible.To nullify its effect, the final comparison of the RSI andcrash intubations were done by removing those caseswith incomplete information. Thus, only 241 cases wereused for inferential statistical calculations, with respect tocomparison between the two modes of intubations. Allother analyses were done on the basis of the total studypopulation (n=278).Data was entered and analysed using SPSS 19. Descriptivestatistics were used to describe patients' demographics,intubation details and occurrence of complications. Meanand standard deviation values were computed forcontinuous variables. Pearson's chi-square test wasconducted to compare categorical variables related to thetwo types of intubations. To compare the age of theunpaired groups, Student's t-test was used. The level ofsignificance was set at p<0.05. The AKUH Ethics ReviewCommittee placed the study in the ethics exemptedcategory.ResultsA total of 278 intubations meeting the inclusion criteriawere performed during the study period. The mean age ofthe study sample was 52±19 years. There were 174 males(63%) in the study.  The most common reason forintubation was an underlying medical condition in221(80%) patients, followed by trauma in 42(15%) patients.The most common diagnoses of patients requiring ETI wascardiogenic pulmonary oedema 76(27%) and head injury25(9%). The most common indication for airwayintervention was hypoxia in 186 (67%) cases when analysedusing multiple response analysis (n=193, 69%) (Figure).EPs made the decision to intubate in 193 (69%) cases.However, the actual procedure was performed by theanaesthesiology team  in 236(85%) cases while the EMteam performed it in 36(13%) cases. The overall successon the first intubation attempt was 230(94%). Of all the intubations, 185(67%) were RSI and 56(20%) wereVol. 63, No.3, March 2013Intubation in emergency department of a tertiary care hospital in a low-income country 307Table: Characteristics of rapid sequence intubation and crash intubation.Variables Method of intubation p-valueRSI (n = 185) Crash intubation (n = 56)Mean age (years) 51 ± 19 53 ± 19 0.47Gender†Male 121 (65%) 29 (52%) 0.06Female 64 (35%) 27 (48%)Underlying condition requiring intubation†Medical 146 (79%) 50 (89%) 0.20Surgical 10 (5%) 2 (4%)Trauma 29 (16%) 4 (7%)Speciality of doctor who made the decision to intubateAnaesthesiology 11 (6%) - 0.01Emergency Medicine 120 (65%) 49 (87%)Medicine 49 (27%) 6 (11%)Surgery 5 (3%) 1 (2%)Speciality of doctor who performed the intubationAnaesthesiology 170 (92%) 31 (55%) 0.0001Emergency Medicine 12 (6.5%) 24 (43%)Medicine 3 (2%) 1 (2%)Number of attemptsFirst 181 (98%) 48 (85%) 0.001Second 4 (2%) 6 (11%)Third 0 2 (4%)+: Student’s t-test.†: Pearson chi-square test.RSI: Rapid sequence intubation.crash intubations. Sedating agents alone were used in19(7%) and paralysing agents were used in 18(6%) cases.Complete RSI and crash intubation cases were compared(Table). The mean time from the arrival of patient in the EDto an intubation decision was 73±103 minutes in RSI, and8±204 minutes in crash intubation. On the other hand, themean time interval from decision to intubation was 27±95minutes in RSI, and 12±20 minutes in crash intubation. Total short-term complications noted in the data were15(5%):  8 in RSI and 7 in crash intubations. Rate ofcomplication for patients in whom the airway was securedin the first attempt was 3%; 22% in the second attempt; and50% in the third attempt. The common complicationsobserved were desaturation (n=3,2%), cardiac arrest(n=2,1%) and hypotension (n=2,1%) in RSI, while oraltrauma (n=3,5%), cardiac arrest (n=2,4%) and regurgitation(n=2,4%) were noted in crash intubation. Out of 278 cases,29(10.43%) had difficult airway, and in 14(5%) patients,more than one anaesthetist was required for the procedure. DiscussionOur study highlighted that RSI was a common type ofintubation in our ED. It also had a better success rate onfirst attempt of intubation compared to the crashintubation. Cardiogenic pulmonary oedema and headinjury were the common diagnoses requiring intubation.Overall, complications were seen in 5% patients withthese intubations. Almost equal numbers ofcomplications were noted in both types of intubations.RSI is a safe and accepted method of intubation in EDpatients. It provides a secure airway in acute conditions,facilitating patient stability even in need oftransportation. However, like all procedures it holds somelevel of risk.12 One study involving 1068 cases of EDintubation over a five-year period reported 51% of theintubations to be orotracheal with no medication,followed by 28% RSI.13 On the contrary, 67% of theintubations in this study data were RSI, while 20% werecrash intubations. The variability in data may be due todifferent patient conditions and skills of the physician inRSI. In our data, RSI was the most common approachbecause in the ED we had anaesthesia rush-call cover 24hours a day and the team is prompt in attending to andintubating patients. Others have reported under-usage ofJ Pak Med Assoc308 N. U. Khan, U. R. Khan, K. Ejaz, H. Ahmad, et al.Figure: Indications for airway intervention.*: Burns, Oropharyngealbleeding, Vomitus, Fall.<: Less than.+: For radiological studies.RSI in the region.11 In England, a study reported 0.12%incidence of ED RSI of which only 20% were performed byEPs. Senior anaesthetic trainees of specialist trainee year 3and above from anaesthesia undertook 80% of ED RSIs.14Our study also found similar findings.Another study showed that there were no differences infailure rates between ED staff and anaesthetists (2.73%  vs0%, p<0.55).12 In our study, most decisions to intubatewere taken by EPs, but were performed by anaesthetists.This can be explained because the protocol followed inthe department was to call for an anaesthetist earlierinstead of attempting to intubate directly. Others havealso reported little or no difference in the success ratesbetween the two groups.10In developed countries, trauma and low Glasgow ComaScale (GCS) score have been identified as the mostcommon indications for intubations. In England, 25% ofRSI were in trauma patients.14 In our data, medicalconditions were responsible for 79% of RSI intubations,while trauma accounted for 16%. In a regional study,stroke and pneumonia were common indications, butnon-traumatic ED patients were studied.11 One studyexplained that diagnoses requiring intubation weremostly cardiopulmonary arrest, congestive heart failureand head injury (38%, 21% and 8% respectively).13 Ourdata also reports 79% of RSI and 89% of crash intubationsdue to medical-related conditions. Trauma was involvedin 16% of RSI and 7% of crash cases. The reason for thisdifference is that our hospital is not a direct referencecentre for trauma. Most of the cases initially go to public-sector hospitals.Regional studies explain hypotension, multiple attemptsand oesophageal intubation as common peri-intubationcomplications.13 Desaturation, cardiac arrest, hypotensionand regurgitation were the common complications in ourdata. We had 15 complications reported, of whichhypotension was reported in 2 cases while 11 casesrequired multiple intubation attempts. Rate ofcomplication altered according to the number ofattempts. It may be inferred that difficult intubation islikely to have more complications. It has been reportedthat soft tissue injury followed by hypotension andoesophageal intubation were major complications in anon-traumatic ED in Bangkok.11 RSI was reported to beunderused in that study. Using RSI might lead to less soft-tissue injury as the muscles are relaxed and intubation issmooth.Major limitations of this study included the retrospectiveapproach and data collection from a single-centre, whichhampers generalisation for mass population. Besides thisthose who died in the ED had to be excluded as the medicalrecord system of the hospital did not code them as in-patient admissions. Similarly, we had to exclude patientsshifted to other hospitals due to non-availability of beds,financial  reasons and patient/family wishes.ConclusionRSI was the most common method used which is in line withrelevant recommendations. Hypoxia was the most frequentindication for intubation. Pulmonary oedema was the mostcommon underlying diagnosis requiring the procedure. Thestudy had a satisfactory success rate in both RSI and crashdespite the fact there were a few complications.References1. Habermann TM, Ghosh AK, Rhodes DJ, Sood A, Murali N, Edson R,et al. Mayo Clinical Internal Medicine Review 2006-2007. 7 ed.New York: Mayo Clinic Scientific Press, 2006; pp 152.2. Mort TC. Complications of emergency tracheal intubation:hemodynamic alterations - part I. J Intensive Care Med 2007; 22:157-65.3. Mort TC. Complications of emergency tracheal intubation:immediate airway-related consequences: part II. J Intensive CareMed 2007; 22: 208-15.4. Gudzenko V, Bittner EA, Schmidt UH. Emergency airwaymanagement. Respir Care 2010; 55: 1026-35.5. Dufour DG, Larose DL, Clement SC. Rapid sequence intubation inthe emergency department. J Emerg Med 1995; 13: 705-10.6. Kovacs G, Law JA, Ross J, Tallon J, MacQuarrie K, Petrie D, et al.Acute airway management in the emergency department by non-anesthesiologists. Can J Anaesth 2004; 51: 174-80.7. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airwaymanagement in the emergency department: a one-year study of610 tracheal intubations. Ann Emerg Med 1998; 31: 325-32.8. Nayyar P, Lisbon A. Non-operating room emergency airwaymanagement and endotracheal intubation practices: a survey ofanesthesiology program directors. Anesth Analg 1997; 85: 62-8.9. Ma OJ, Bentley B, 2nd, Debehnke DJ. Airway management practices inemergency medicine residencies. Am J Emerg Med 1995; 13: 501-4.10. Dibble CP, McHague C. Rapid sequence intubations by emergencydoctors: we can but are we? Emerg Med J 2007; 24: 480-1.11. Wongyingsinn M, Songarj P, Assawinvinijkul T. A prospectiveobservational study of tracheal intubation in an emergencydepartment in a 2300-bed hospital of a developing country in aone-year period. Emerg Med J 2009; 26: 604-8.12. Fullerton JN, Roberts KJ, Wyse M. Should non-anaesthetistsperform pre-hospital rapid sequence induction? an observationalstudy. Emerg Med J 2010; 28: 428-31.13. Wong E, Fong YT, Ho KK. Emergency airway management--experienceof a tertiary hospital in South-East Asia. Resuscitation 2004; 61: 349-55.14. Benger J, Hopkinson S. Rapid sequence induction of anaesthesiain UK emergency departments: a national census. Emerg Med J2011; 28: 217-20.Vol. 63, No.3, March 2013Intubation in emergency department of a tertiary care hospital in a low-income country 309

Intubation in emergency department of a tertiary care hospital in a low-income

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Intubation in emergency department of a tertiary care hospital in a low-income

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