ORCID Profile
0000-0002-7299-1363
Current Organisation
University of Tasmania
Does something not look right? The information on this page has been harvested from data sources that may not be up to date. We continue to work with information providers to improve coverage and quality. To report an issue, use the Feedback Form.
Publisher: Informa UK Limited
Date: 29-01-2018
DOI: 10.1080/10903127.2017.1423139
Abstract: Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS 97% (95% CI 96-98) vs. 98% (95% CI 91-100), and no difference in first-pass success for flight compared to ground based RSI 82% (95% CI 73-89) vs. 82% (95% CI 70-93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98-100) vs. 96% (95% CI 94-97) and first-pass success 89% (95% CI 77-98) vs. 71% (95% CI 57-84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88-100) vs. 98% (95% CI 95-100), but no analysis for physician ground first pass was possible. Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.
Publisher: Wiley
Date: 09-04-2021
DOI: 10.1111/ACEM.14256
Abstract: Rapid sequence intubation (RSI) is used to secure the airway of traumatic brain injury (TBI) patients, with ketamine frequently used for induction. Studies show that ketamine‐induction RSI might cause lower blood pressures when compared to etomidate. It is not clear if the results from that research can be extrapolated to systems that use different dosing regimens for ketamine RSI. Ambulance Victoria authorized the use of 1.5 mg/kg ketamine in January 2015 for head injury RSI induction by road‐based paramedics. This study aims to examine whether systolic blood pressure changed when ketamine was introduced for prehospital head injury RSI. This study was a retrospective analysis of out‐of‐hospital suspected TBI that received RSI by paramedics. Our analysis employs an interrupted time‐series analysis (ITSA), which is a quasi‐experimental method that tested whether hypotension and systolic blood pressures changed after the switch to ketamine induction in 2015. This ITSA utilized an ordinary least squares regression on complete observations using Newey–West standard errors. During the study period, paramedics performed RSI in 8,613 patients, and 1,759 (20.4%) had a TBI. Ketamine usage increased by 52.7% in January 2015 (p 0.001) after road‐based paramedics were authorized to use ketamine induction. This analysis found significant 5% increase in post‐RSI hypotension (p = 0.046) after the introduction of ketamine, and thereafter the incidence of post‐RSI hypotension increased steadily by 0.5% every 3 months (p = 0.004). Concurrently, changes in systolic blood pressure, as measured by the interval just before induction to the last measured on scene, show an average decrease of 7.8 mm Hg (p = 0.04) at the start of 2015 with the ketamine rollout. This ITSA shows that postinduction hypotension and also decreases in systolic blood pressures became evident after the introduction of ketamine. Further research to investigate the association between ketamine induction and survival is needed.
Publisher: SAGE Publications
Date: 15-05-2023
DOI: 10.1177/27536386231175520
Abstract: Advanced airway interventions, including endotracheal intubation (ETI) and supraglottic airway devices (iGel ® ), are used for airway management. Advanced airway proficiency is critical to maintain patient safety. Airway registries are commonly used quality assurance tools that can drive system-level improvement. This study analyses the first two years of data from a new prehospital airway registry. This is a retrospective review of the first two years of an airway registry for Intensive Care Paramedics in New South Wales Ambulance spanning 8 August 2020 to 8 August 2022. Changes in airway management effectiveness were examined as a time series and analysis proceeded regression using Newey–West standard errors. Additionally, a machine learning algorithm (generalised boosted model) was used to predict successful ETI. There were 872 unique advanced airway episodes suitable for analysis. Of 705 patients that had received ETI, 655 were successful resulting in an overall success rate of 92.9%. Intubation was achieved on the first attempt in 573 out of 705 (81.3%) patients. Supraglottic airway insertion was successful in 193 of 222 patients (86.9%). The first-pass success for the iGel ® supraglottic device was 183 of 222 (82.4%). Considerable increases in ETI and iGel ® first-pass success were observed over time. A machine learning analysis demonstrated that factors predicting success for endotracheal intubation included airway-grade, patient age, the use of video laryngoscopy, patient weight and the use of external laryngeal manipulation/bi-manual laryngoscopy. This prehospital airway registry analysis demonstrates increasing advanced airway success over the first two years of registry implementation. These increases may be explained in part by the reflective feedback and awareness of airway management that results from the registry, training and the increased use of video laryngoscopy.
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.ANNEMERGMED.2017.03.026
Abstract: Rapid sequence intubation performed by nonphysicians such as paramedics or nurses has become increasingly common in many countries however, concerns have been stated in regard to the safe use and appropriateness of rapid sequence intubation when performed by these health care providers. The aim of our study is to compare rapid sequence intubation success and adverse events between nonphysician and physician in the out-of-hospital setting. A systematic literature search of key databases including MEDLINE, EMBASE, and the Cochrane Library was conducted. Eligibility, data extraction, and assessment of risk of bias were assessed independently by 2 reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success and for adverse events when possible. Eighty-three studies were included in the meta-analysis. There was a 2% difference in successful intubation proportion for physicians versus nonphysicians, 99% (95% confidence interval [CI] 98% to 99%) versus 97% (95% CI 95% to 99%). A 10% difference in first-pass rapid sequence intubation success was noted between physicians versus nonphysicians, 88% (95% CI 83% to 93%) versus 78% (95% CI 65% to 89%). For airway trauma, bradycardia, cardiac arrest, endobronchial intubation, hypertension, and hypotension, lower prevalences of adverse events were noted for physicians. However, nonphysicians had a lower prevalence of hypoxia and esophageal intubations. Similar proportions were noted for pulmonary aspiration and emesis. Nine adverse events estimates lacked precision, except for endobronchial intubation, and 4 adverse event analyses showed evidence of possible publication bias. Consequently, no reliable evidence exists for differences between physicians and nonphysicians for adverse events. This analysis shows that physicians have a higher rapid sequence intubation first-pass and overall success, as well as mostly lower rates of adverse events for rapid sequence intubation in the out-of-hospital setting. Nevertheless, for all success and adverse events no firm conclusion for a difference could be drawn because of lack of precision of meta-analytic estimates or selective reporting. First-pass success could be an area in which to focus quality improvement strategies for nonphysicians.
Publisher: Springer Science and Business Media LLC
Date: 2013
DOI: 10.1186/CC11924
Publisher: Elsevier BV
Date: 09-2014
Publisher: Wiley
Date: 30-04-2019
Abstract: Endotracheal intubation is an advanced airway procedure performed in the ED and the out-of-hospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non-traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirty-nine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.
Publisher: Informa UK Limited
Date: 16-06-2017
DOI: 10.1080/10903127.2017.1325952
Abstract: Rapid sequence intubation (RSI) is not only used in traumatic brain injuries in the out-of-hospital setting, but also for non-traumatic brain pathologies (NTBP) such as brain tumors, meningitis, encephalitis, hypoxic/anoxic brain injury, stroke, arteriovenous malformations, tumors, aneurysms, brain hemorrhage, as well as brain injury due to diabetes, seizures and toxicity, metabolic conditions, and alcohol and drug overdose. Previous research suggests that RSI is common in non-traumatic coma, but with an unknown prevalence of NTBP in those that receive RSI. If NTBP is common and if brain trauma RSI evidence is not valid for NTBP then a sizable proportion of NTBP receive this treatment without evidence of benefit. This study calculated the out-of-hospital NTBP prevalence in patients that had received RSI and explored factors that predicted survival. A retrospective cohort study based on data collected from an ambulance service and seven hospitals based in Melbourne, Australia. Non-traumatic brain pathologies were defined using ICD10-AM codes for the calculation of NTBP prevalence. Logistic regression modelled out-of-hospital predictors of survival to hospital discharge after adjustment for comorbidities. The seven participating hospitals treated 2,277 patients that received paramedic RSI for all illnesses and indications from January 1, 2008 to December 31, 2015, with survival data available for 1,940 (85%). Of the 1,940, 1,125 (58%) patients had at least one hospital-diagnosed NTBP. Sixty-nine percent all of NTBP survived to hospital discharge, compared to 65% for traumatic intracranial injury. Strokes were the most common and had poor survival to discharge (37%) compared to the second most common NTBP toxicity/toxic encephalopathy that had very high survival (98%). No out-of-hospital clinical intervention or prehospital time interval predicted survival. Factors that did predict survival include Glasgow Coma Scale (GCS), duration of mechanical ventilation, age, ICU length of stay, and comorbidities. Non-traumatic brain pathologies are seven times more prevalent than traumatic brain injuries in patients that underwent out-of-hospital RSI in Victoria, Australia. Since the mechanisms through which RSI impacts mortality might differ between traumatic brain injuries and NTBP, and given that NTBP is very prevalent, it follows that the use of RSI in NTBP could be unsupported.
Publisher: Wiley
Date: 06-04-2015
Publisher: Elsevier BV
Date: 02-2016
Publisher: Wiley
Date: 18-06-2022
Abstract: Video laryngoscopy (VL) is increasingly used as an alternative to direct laryngoscopy (DL) to improve airway visualisation and endotracheal intubation (ETI) success. Intensive Care Paramedics in New South Wales Ambulance, Australia started using VL in 2020, and recorded success in a new advanced airway registry. We used this registry to compare VL to DL. The present study was a retrospective analysis of out-of-hospital data for ETI by specialist paramedics using an airway registry. We calculated overall and first-pass success for VL versus DL, and compared success using a Χ The DL overall success was 61 out of 78 (78.2%) and VL was 233 out of 246 (94.7%) difference of 16.5% (P < 0.001). First-pass for DL was successful for 49 out of 78 (62.8%) and for VL in 195 out of 246 (79.3%) difference of 16.5% (P = 0.003). There were five (1.6%) patients where both VL and DL were used and in all instances, DL was used first. This analysis of a new airway registry used by specialist paramedics in New South Wales shows a substantial increase in overall and first-pass intubation success with the use of VL when compared to DL.
Publisher: Wiley
Date: 09-08-2020
Publisher: Springer Science and Business Media LLC
Date: 28-01-2020
DOI: 10.1186/S12873-020-0303-9
Abstract: Rapid sequence intubation (RSI) is used to secure the airway of stroke patients. Randomized controlled trial evidence exists to support the use of paramedic RSI for traumatic brain injury (TBI), but cannot necessarily be applied to stroke RSI because of differences between the stroke and TBI patient. To understand if the TBI evidence can be used for stroke RSI, we analysed a retrospective cohort of TBI and strokes to compare how survival is impacted differently by RSI when comparing strokes and TBI. This study was a retrospective analysis of 10 years of in-hospital and out-of-hospital data for all stroke and TBI patients attended by Ambulance Victoria, Australia. Logistic regression predicted the survival for ischemic and haemorrhagic strokes as well as TBI. The constituents of RSI, such a medications, intubation success and time intervals were analysed against survival using interactions to asses if RSI impacts survival differently for strokes compared to TBI. This analysis found significant interactions in the RSI-only group for age, number of intubation attempts, atropine, fentanyl, pulse rate and perhaps scene time and time- to-RSI. Such interactions imply that RSI impact survival differently for TBI versus strokes. Additionally, no significant difference in survival for TBI was found, with a − 0.7% lesser survival for RSI compared to no-RSI OR 0.86 (95% CI 0.67 to 1.11 p = 0.25). Survival for haemorrhagic stroke was − 14.1% less for RSI versus no-RSI OR 0.44 (95% CI 0.33 to 0.58 p = 0.01) and was − 4.3% OR 0.67 (95% CI 0.49 to 0.91 p = 0.01) lesser for ischemic strokes. Rapid sequence intubation and related factors interact with stroke and TBI, which suggests that RSI effects stroke survival in a different way from TBI. If RSI impact survival differently for strokes compared to TBI, then perhaps the TBI evidence cannot be used for stroke RSI.
Publisher: Elsevier BV
Date: 05-2016
Publisher: BMJ
Date: 16-07-2021
DOI: 10.1136/EMERMED-2020-210887
Abstract: Rapid Sequence intubation (RSI) is an airway procedure that uses sedative and paralytic drugs to facilitate endotracheal intubation. It is known that RSI could impact blood pressure in the peri-intubation period. However, little is known about blood pressure changes in longer time frames. Therefore, this analysis aims to describe the changes in systolic blood pressure in a large cohort of paramedic-led RSI cases over the whole prehospital timespan. Intensive Care Paramedics in Victoria, Australia, are authorised to use RSI in medical or trauma patients with a Glasgow Coma Scale . This retrospective cohort study analysed data from patientcare records for patients aged 12 years and above that had received RSI, from 1 January 2008 to 31 December 2019. This study quantifies the systolic blood pressure changes using regression with fractional polynomial terms. The analysis is further stratified by high versus Low Shock Index (LSI). The shock index is calculated by iding pulse rate by systolic blood pressure. During the study period RSI was used in 8613 patients. The median number of blood pressure measurements was 5 (IQR 3–8). Systolic blood pressure rose significantly by 3.4 mm Hg (p .001) and then returned to baseline in the first 5 min after intubation for LSI cases. No initial rise in blood pressure is apparent in High Shock Index (HSI) cases. Across the whole cohort, systolic blood pressure decreased by 7.1 mm Hg (95% CI 7.9 to 6.3 mm Hg p .001) from the first to the last blood pressure measured. Our study shows that in RSI patients a small transient elevation in systolic blood pressure in the immediate postintubation period is found in LSI, but this elevation is not apparent in HSI. Blood pressure decreased over the prehospital phase in RSI patients with LSI, but increased for HSI cases.
Publisher: Informa UK Limited
Date: 10-10-2013
DOI: 10.3109/10903127.2013.831509
Abstract: To determine the differences in survival for out-of-hospital advanced airway intervention (AAI) compared with basic airway intervention (BAI) in cardiac arrest. AAI is commonly utilized in cardiac arrest in the out-of-hospital setting as a means to secure the airway. Observational studies and clinical trials of AAI suggest that AAI is associated with worse outcomes in terms of survival. No controlled trials exist that compares AAI to BAI. We conducted a bias-adjusted meta-analysis on 17 observational studies. The outcomes were survival, short-term (return of spontaneous circulation and to hospital admission), and longer-term (to discharge, to one month survival). We undertook sensitivity analyses by analyzing patients separately: those who were 16 years and older, nontrauma only, and attempted versus successful AAI. This meta-analysis included 388,878 patients. The short-term survival for AAI compared to BAI were overall OR 0.84(95% CI 0.62 to 1.13), for endotracheal intubation (ETI) OR 0.79 (95% CI 0.54 to 1.16), and for supraglottic airways (SGA) OR 0.59 (95% CI 0.39 to 0.89). Long-term survival for AAI were overall OR 0.49 (95% CI 0.37 to 0.65), for ETI OR 0.48 (95% CI 0.36 to 0.64), and for SGA OR 0.35 (95% CI 0.28 to 0.44). Sensitivity analyses shows that limiting analyses to adults, non-trauma victims, and instances where AAI was both attempted and successful did not alter results meaningfully. A third of all studies did not adjust for any other confounding factors that could impact on survival. This meta-analysis shows decreased survival for AAIs used out-of-hospital in cardiac arrest, but are likely biased due to confounding, especially confounding by indication. A properly conducted prospective study or a controlled trial is urgently needed and are possible to do.
Publisher: Elsevier BV
Date: 2017
DOI: 10.1016/J.RESUSCITATION.2016.10.020
Abstract: Previous research demonstrates that results from observational research correlate well with results from clinical trials, and if the former are well designed these can guide clinical practice. Observational studies in cardiac arrest research are beset by confounding due to illness severity and comorbidity. We aimed to count the number of studies that utilize comorbidity and illness severity scores and indices, and to measure the change in results across analyses that adjust for scores and indices. A systematic search of databases for cardiac arrest studies that report survival outcomes for 2015 and that utilize illness severity and comorbidity indices and scores was conducted. We quantified the proportion of studies and the change in magnitude of estimates when adjustment for indices and scores were used. Sixty (28%) of 213 cardiac arrest studies that report survival outcomes utilize illness severity or comorbidity indices and scores, of which 39 studies (65%) used risk scores and indices to account for the confounding effect of comorbidity or illness severity. A 14% change towards the null in the magnitude of effect sizes was apparent when models included illness severity or comorbidity adjustment (interquartile range -37.7 to 4.4). A small proportion of cardiac arrest studies account for illness severity and comorbidity with scores and indices, and such adjustment tend to drive estimates towards the null (no difference in groups being compared). Confounding by illness severity and comorbidity is a significant source of bias in non-randomized cardiac arrest studies.
Publisher: Wiley
Date: 19-10-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2013
Publisher: BMJ
Date: 30-05-2019
DOI: 10.1136/EMERMED-2019-208613
Abstract: Ambulance transport of patients with stroke is common, with rapid sequence intubation (RSI) to secure the airway used regularly. Randomised controlled trial evidence exists to support the use of RSI in traumatic brain injuries (TBIs), but it is not clear whether the RSI evidence from TBI can be applied to the patient with stroke. To this end, we analysed a retrospective stroke dataset to compare survival of patients with RSI compared with patients that did not receive RSI. This study was a retrospective analysis of 10 years of in-hospital and out-of-hospital data for all patients with stroke attended by Ambulance Victoria, in Victoria Australia. Generalised boosted logistic regression was used to predict propensity scores, with initial vital signs, age and demographic variables as well as measures of illness severity and comorbidity included in the prediction model. This analysis employed a 1:1 nearest-neighbour matching which was applied to generate a dataset from which we calculated the OR of survival to hospital discharge of patients receiving RSI versus no-RSI. The sensitivity of these results to unmeasured confounding was assessed with deterministic sensitivity analysis. The propensity score-matched cohort showed a decreased survival for RSI in strokes with an OR 0.61 (95% CI 0.45 to 0.82 p=0.001) when compared with no-RSI. A subgroup analysis showed no significant survival difference for ischaemic strokes: OR 0.66 (95% CI 40 to 1.07 p=0.09). The survival for haemorrhagic stroke was OR 0.60 (95% CI 0.41 to 0.90 p=0.01) lesser for RSI. Results were likely robust to unmeasured confounding and missing data. Our retrospective analysis shows a decrease in survival when RSI is utilised by paramedics for stroke. Since RSI is commonly used for strokes, controlled trial evidence to support this practice is urgently needed.
Publisher: Springer Science and Business Media LLC
Date: 04-07-2016
No related grants have been discovered for Pieter Fouche.