EducationVideo analysis of Emergency Medicine residents performing rapid-sequence intubations1
Introduction
Patients presenting to the Emergency Department (ED) fre- quently need emergent intubation. Many of these are done by the rapid-sequence intubation (RSI) technique. This allows for rapid airway management while minimizing the risk of aspiration 1, 2. The protocol for RSI is well-defined and widely accepted throughout the Emergency Medicine literature 1, 2, 3, 4, 5. Walls described this protocol, which includes the five “P’s”: preparation, preoxygenation, pretreatment, paralyzing the patient, and passing the tube 1, 2, 5.
RSI is a skill that Emergency Medicine resident physicians must master during their training program. The specific skills are generally learned through “hands-on” experience while working in the ED or operating room. Evaluation of skills comes primarily from informal feedback by attending physicians after the procedure. This feedback, however, is relatively subjective and based on recollection of events that occur rapidly. Without proper feedback and correction of mistakes, improper habits may escape detection and become entrenched. Videotaping resident physicians performing RSI may provide a more objective measure of their skills. The primary purpose of this study was to evaluate resident physicians’ performance of RSI compared with our institution’s standard RSI protocol by the use of videotape analysis. A secondary purpose of the study was to compare residents’ actual performance of RSI on videotape with their immediate recall of their performance after the procedure.
Section snippets
Materials and methods
An observational prospective study using a convenience sample was conducted at a suburban, level 1 trauma, 600-bed teaching hospital. The resident physicians involved in the study signed a consent form beforehand allowing the videotaping, and they were aware of the purpose of the study. Consent for review of the videotape was obtained after the procedure from family members of the patients intubated. If consent was refused or the family members were unavailable, the videotape was immediately
Results
Forty-four RSIs performed by 33 residents (14 EM-1, 8 EM-2, 11 EM-3) were studied from July 1996−June 1998. The percentage of deviations for specific steps (Table 2 ) include: Sellick maneuver from paralysis until confirmation of tube placement (45%), end-tidal CO2 detector use (34%), pulse oximetry check postintubation (14%), pretreatment dose of a nondepolarizing paralytic agent (11%), appropriate preoxygenation (9%), pulse oximetry placed preintubation (9%), suction set-up (7%), endotracheal
Discussion
RSI is a skill that Emergency Medicine resident physicians must master. Traditionally, this is performed in the ED or the operating room under the direct supervision of an attending physician. Feedback regarding performance comes primarily from informal discussion after the procedure. This feedback, however, is subjective and based upon recollection of events that occur rapidly, with important details possibly being overlooked. Videotaping the procedure and providing feedback based upon review
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Cited by (26)
Technology-Enhanced Simulation Training for Pediatric Intubation
2015, Clinical Pediatric Emergency MedicineThe Traumatized Airway
2013, Benumof and Hagberg's Airway ManagementThe Traumatized Airway
2012, Benumof and Hagberg's Airway Management: Third EditionRapid sequence intubation for pediatric emergency patients: Higher frequency of failed attempts and adverse effects found by video review
2012, Annals of Emergency MedicineCitation Excerpt :Also, the detection of adverse effects depended on accurate recording in the written record. As noted above, we believe that differences in methodology explain most of the observed differences between our study and the existing literature and that the true frequencies of first-attempt failure and adverse effects for children undergoing RSI in an ED are closer to our findings.10,21-24 To our knowledge, our study is the first to report a detailed description of the timing of the RSI process for ED patients, making possible an objective evaluation of published recommendations for the duration of various RSI intervals.
Use of cricoid pressure during rapid sequence induction: Facts and fiction
2012, Trends in Anaesthesia and Critical CareCitation Excerpt :In summary, the belief that CP may not be of proven benefit, but neither is it of any proven harm, is fiction. In general, anaesthesia and emergency personnel lack knowledge about theoretical as well as practical aspects of CP.3,45–48 Technical limitations include incorrect location (compression of thyroid instead of cricoid cartilage), use of too low as well as excessive force, irreproducibility of effective cricoid forces, and uncertainty as to when to begin applying CP (in the awake vs. the asleep patient).5,9,56
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Education is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California