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Wang CH, Li JD, Wu CY, Wu YC, Tay J, Wu MC, Hsu CH, Liu YK, Chen CS, Huang CH. Application of Machine Learning to Ultrasonography in Identifying Anatomical Landmarks for Cricothyroidotomy Among Female Adults: A Multi-center Prospective Observational Study. JOURNAL OF IMAGING INFORMATICS IN MEDICINE 2024; 37:363-373. [PMID: 38343208 PMCID: PMC11031510 DOI: 10.1007/s10278-023-00929-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 03/02/2024]
Abstract
We aimed to develop machine learning (ML)-based algorithms to assist physicians in ultrasound-guided localization of cricoid cartilage (CC) and thyroid cartilage (TC) in cricothyroidotomy. Adult female volunteers were prospectively recruited from two hospitals between September and December, 2020. Ultrasonographic images were collected via a modified longitudinal technique. You Only Look Once (YOLOv5s), Faster Regions with Convolutional Neural Network features (Faster R-CNN), and Single Shot Detector (SSD) were selected as the model architectures. A total of 488 women (mean age: 36.0 years) participated in the study, contributing to a total of 292,053 frames of ultrasonographic images. The derived ML-based algorithms demonstrated excellent discriminative performance for the presence of CC (area under the receiver operating characteristic curve [AUC]: YOLOv5s, 0.989, 95% confidence interval [CI]: 0.982-0.994; Faster R-CNN, 0.986, 95% CI: 0.980-0.991; SSD, 0.968, 95% CI: 0.956-0.977) and TC (AUC: YOLOv5s, 0.989, 95% CI: 0.977-0.997; Faster R-CNN, 0.981, 95% CI: 0.965-0.991; SSD, 0.982, 95% CI: 0.973-0.990). Furthermore, in the frames where the model could correctly indicate the presence of CC or TC, it also accurately localized CC (intersection-over-union: YOLOv5s, 0.753, 95% CI: 0.739-0.765; Faster R-CNN, 0.720, 95% CI: 0.709-0.732; SSD, 0.739, 95% CI: 0.726-0.751) or TC (intersection-over-union: YOLOv5s, 0.739, 95% CI: 0.722-0.755; Faster R-CNN, 0.709, 95% CI: 0.687-0.730; SSD, 0.713, 95% CI: 0.695-0.730). The ML-based algorithms could identify anatomical landmarks for cricothyroidotomy in adult females with favorable discriminative and localization performance. Further studies are warranted to transfer this algorithm to hand-held portable ultrasound devices for clinical use.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jia-Da Li
- NTU Joint Research Center for AI Technology and All Vista Healthcare, National Taiwan University, Taipei, Taiwan
| | - Cheng-Yi Wu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chen Wu
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Joyce Tay
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Che Wu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hang Hsu
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Yi-Kuan Liu
- NTU Joint Research Center for AI Technology and All Vista Healthcare, National Taiwan University, Taipei, Taiwan
| | - Chu-Song Chen
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan.
- Institute of Information Science, Academia Sinica, Taipei, Taiwan.
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Sotoodehnia M, Khodayar M, Jalali A, Momeni M, Safaie A, Abdollahi A. Prediction of difficult laryngoscopy / difficult intubation cases using upper airway ultrasound measurements in emergency department: a prospective observational study. BMC Emerg Med 2023; 23:78. [PMID: 37491186 PMCID: PMC10369745 DOI: 10.1186/s12873-023-00852-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/19/2023] [Indexed: 07/27/2023] Open
Abstract
INTRODUCTION Difficult laryngoscopy and intubation are serious problems among critically ill patients in emergency department (ED) so utility of a rapid, accurate and noninvasive method for predicting of these patients are necessary. Ultrasonography has been recently used in this regard and this study was conducted to investigate the correlation of some introduced upper airway ultrasound parameters with difficult laryngoscopy / difficult intubation in patients referred to the ED. METHOD In this prospective observational study all patients ≥ 18-year-old who had an indication for rapid sequence intubation (RSI) were included. Ultrasound parameters including Hyoid Bone Visibility (HBV), Distance from Skin to Hyoid Bone (DSHB), Distance from Skin to Vocal Cords (DSVC), Distance from Skin to Thyroid Isthmus (DSTI), and Distance between Arytenoids Cartilages (DBAC) were measured in all cases. The patients underwent RSI and thereafter the patients' baseline characteristics, Cormack-Lehane grade, number of attempted laryngoscopy were recorded in a pre-prepared check list and compared with measured ultrasound parameters. The "difficult laryngoscopy" was defined as Cormack-Lehane classification grades III/IV; and need for more than 3 intubation attempts was considered as "difficult intubation". RESULTS One hundred and twenty-three patients (52% male) were included of whom 10 patients (8.1%) were categorized as difficult laryngoscopy cases; and just 4 (3.3%) cases underwent more than 3 laryngoscopy attempts who considered as difficult intubation cases. The mean age of the patients in non-difficult and difficult intubation groups were 69.2 ± 15.16 and 68.77 ± 17.37 years, respectively (p > 0.05). There was no significant relationship between difficult laryngoscopy and HBV (p = 0.381) but has significant correlation with difficult intubation (p = 0.004). The DSHB had a significant correlation with difficult laryngoscopy (p = 0.002) but its correlation with difficult intubation was not significant (p = 0.629). The DSVC and DSTI had a significant relationship with both difficult laryngoscopy (p = 0.003 and p = 0.001), and difficult intubation (p = 0.025 and p = 0.001). The DBAC had not significant correlation neither with the difficult laryngoscopy (p = 0.142), nor with difficult intubation (p = 0.526). CONCLUSION The findings showed that ultrasound parameters including soft tissue DSHB, DSVC and DSTI could be proper predictors of difficult laryngoscopy. Also, HBV, DSVC and DSTI may be proper predictors for difficult intubation. But DBAC was not useful in this regard.
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Affiliation(s)
- Mehran Sotoodehnia
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Khodayar
- Imam Hossein Center for Education Research and Treatment, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Alireza Jalali
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Emergency Medicine, Sina Hospital, Terhran, Iran.
| | - Mehdi Momeni
- Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Safaie
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Abdollahi
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Suzuki K, Yambe N, Hojo K, Komatsu Y, Serikawa M, Usami A. Anatomical morphometry for Cricothyrotomy puncture and incision. BMC Surg 2023; 23:198. [PMID: 37438728 DOI: 10.1186/s12893-023-02100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023] Open
Abstract
PURPOSE Emergency surgical airway securing techniques include cricothyrotomy, puncture, and incision. While the instruments used for these methods vary in size, no index of laryngeal morphology exists to guide instrument selection. Therefore, we measured the morphology of the cricothyroid ligament in Japanese individuals and assessed its correlations with height. METHODS This retrospective study used 61 anatomical practice specimens. The cricothyroid ligament of the laryngeal area was dissected, and a frontal image was recorded. Next, images of the midsagittal sections of the larynx and trachea were recorded. The width and height of the cricothyroid ligament were measured from the frontal images, and the depth of the larynx and the angle to the lower edge of the cricothyroid plate were measured from the mid-sagittal cross-sectional images. The height was estimated from the tibial lengths of the specimens and statistically analyzed for correlations. RESULTS: The width and depth were significantly greater in males. Overall, there was a slight correlation between the results of each laryngeal measurement and estimated height for all items. CONCLUSION The morphology of cricothyrotomy revealed that the width and depth of the laryngeal area varied according to sex. Moreover, the results also showed a correlation with the estimated height. Thus, it is important to predict the morphology of the laryngeal area and cricothyroid ligament by considering factors such as patient sex, weight, and height.
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Affiliation(s)
- Kaiji Suzuki
- Department of Oral Functional Anatomy, Graduate School of Dentistry, Ohu University, Koriyama, Japan
| | - Naohito Yambe
- Community Medicine Support Dentistry, Ohu University Hospital, Koriyama, Japan
| | - Kentaro Hojo
- Department of Oral Anesthesia, School of Dentistry, Ohu University, Koriyama, Japan
| | - Yasunori Komatsu
- Department of Oral Anesthesia, School of Dentistry, Ohu University, Koriyama, Japan
| | - Masamitsu Serikawa
- Department of Morphological Biology, School of Dentistry, Ohu University, Koriyama, Japan
| | - Akinobu Usami
- Department of Morphological Biology, School of Dentistry, Ohu University, Koriyama, Japan.
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Almeida CEDD, Carvalho LRD, Andrade CVC, Nascimento PD, Barros GAMD, Modolo NSP. Effects of magnesium sulphate on the onset time of rocuronium at different doses: a randomized clinical trial. Braz J Anesthesiol 2021; 71:482-488. [PMID: 34403648 PMCID: PMC9373264 DOI: 10.1016/j.bjane.2021.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022] Open
Abstract
Background and aims Rocuronium may provide excellent onset time, but high doses are required for effective action. Several strategies have managed to shorten rocuronium onset time, including the use of Magnesium Sulphate (MgSO4). Methods One hundred and eighty patients were randomized into six groups according to rocuronium dose received (0.3, 0.6 or 1.2 mg.kg-1) and the administration of saline or MgSO4 (60 mg.kg-1). Correlations between tissue perfusion and rocuronium onset time was determined by variations in perfusion index. Results Median (quartiles) rocuronium onset times were 85.5 (74.0–92.0); 76.0 (52.0–87.0) and 50.0 (41.0–59.5) seconds for 0.3, 0.6 mg.kg-1 and 1.2 mg.kg-1 doses, respectively. MgSO4 decreased rocuronium onset at doses of 0.3 mg.kg-1 (60.0 [48.0–74.3] seconds) and 0.6 mg.kg-1 (44.0 [39.0–49.0] seconds) but not at 1.2 mg.kg-1 (38.0 [33.5–56.3] seconds) (p < 0.001). Perfusion index variations in groups that received MgSO4 were greater than in controls. A negative correlation between shorten onset and increased perfusion index was observed in rocuronium doses of 0.3 mg.kg-1 (r = -0.50; p < 0.001) and 0.6 mg.kg-1 (r = -0.424; p < 0.001), but not for 1.2 mg.kg-1 dose (r = -0.25; p = 0.07). Conclusion MgSO4 reduces rocuronium onset time at doses of 0.3 mg.kg-1 and 0.6 mg.kg-1 being that the latter has a similar effect when compared to the dose of 1.2 mg.kg-1, with or without the use of MgSO4. Trial registry at http://www.ensaiosclinicos.gov.br/ Registry Number RBR-96CY3K
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Affiliation(s)
- Carlos Eduardo David de Almeida
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Programa de Pós-Graduação em Anestesiologia, Botucatu, SP, Brazil
| | | | - Carla Vasconcelos Caspar Andrade
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Programa de Pós-Graduação em Anestesiologia, Botucatu, SP, Brazil
| | - Paulo do Nascimento
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Divisão de Anestesiologia, Botucatu, SP, Brazil
| | | | - Norma Sueli Pinheiro Modolo
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Divisão de Anestesiologia, Botucatu, SP, Brazil
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Enright K, Akram S, Hussain A, Powell CVE. The integral role of the clinical pharmacist in drug-assisted intubation at a newly established children's major trauma center. Int J Clin Pharm 2021; 43:1128-1132. [PMID: 33851287 PMCID: PMC8043096 DOI: 10.1007/s11096-021-01262-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/24/2021] [Indexed: 11/27/2022]
Abstract
This commentary outlines how the clinical pharmacist can support the safe administration of emergency medications in trauma anesthesia for seriously injured children. Promoting the professional development of the clinical pharmacist provided an opportunity to strengthen a key step in our trauma care pathway. We describe the implementation of this process in a new hospital, which was to become the designated children's trauma center for an entire country. Although the literature documents the use of pharmacists in emergency intubation, ours was a unique set of circumstances, where empowering the pharmacist in frontline clinical care provided additional quality assurance for rapid sequence induction and intubation in trauma. Medical simulation was a core part of socializing the advanced clinical practice role of pharmacy within the trauma team. It was our experience that the pharmacist helps to promote confidence and decision making among other members of the trauma team.
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Affiliation(s)
- Kevin Enright
- Department of Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar.
| | - Shazia Akram
- Department of Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
| | - Amna Hussain
- Department of Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
| | - Colin V E Powell
- Department of Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Mbanjumucyo G, Aluisio A, Cattermole GN. Characteristics, physiology and mortality of intubated patients in an emergency care population in sub-Saharan Africa: a prospective cohort study from Kigali, Rwanda. Emerg Med J 2021; 38:178-183. [PMID: 33436483 DOI: 10.1136/emermed-2019-208521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 11/01/2020] [Accepted: 11/08/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Formalised emergency departments (ED) are in early development in sub-Saharan Africa and there are limited data on emergency airway management in those settings. This study evaluates characteristics and outcomes of ED endotracheal intubation, as well as risk factors for mortality, at a teaching hospital in Rwanda. METHODS This was a prospective observational study of consecutive patients requiring endotracheal intubation at the University Teaching Hospital of Kigali ED conducted between 1 January and 31 December 2017. A standardised data collection tool was used to record patient demographics, preintubation clinical presentation, indication for intubation, vital signs. medications and equipment used, and periintubation complications. The primary outcome was in-hospital mortality. Univariate associations were determined for risks of mortality. RESULTS Of 198 intubations were analysed, 72.7% were male and the median age was 35 years (IQR 23-51). Airway protection was the most common indication for intubation (73.7%). Rapid sequence intubation was performed in 74.2% of cases; sedative-only facilitated intubation in 20.6% and non-drug assisted in 5.2%. The most common agents used were Ketamine for sedation (85.4%) and vecuronium for paralysis (65.7%). All patients were successfully intubated within three attempts, 85.4% on the first attempt. During intubation, 23.1% of patients experienced hypoxia, 6.7% aspiration and 3.6% cardiac arrest. Median ED length of stay was 2 days. Outcome data were available for 164 patients of whom 67.7% died. Bonferroni-corrected univariate analysis demonstrated that mortality was associated with higher postintubation shock index (p=0.0007) and lower postintubation systolic blood pressure (SBP) (p=0.0006). CONCLUSION The first-attempt and overall success rates for intubation in this ED in Rwanda were comparable to those in high-income countries (HIC). Mortality postintubation is associated with lower postintubation SBP and higher postintubation shock index. The high complication and mortality rates suggest the need for better resources and training to address differences in compared with HIC.
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Affiliation(s)
- Gabin Mbanjumucyo
- Emergency medicine, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Adam Aluisio
- Emergency medicine, Brown University Alpert Medical School, Providence, Rhode Island, USA
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Chan GWH, Chai CY, Teo JSY, Tjio CKE, Chua MT, Brown III CA. Emergency airway management in a Singapore centre: A registry study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:42-51. [PMID: 33623957 DOI: 10.47102/annals-acadmedsg.2020331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore. METHODS We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described. RESULTS There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians. CONCLUSION In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.
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Affiliation(s)
- Gene Wai Han Chan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
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Tang TH, Yang MLC, Chan OY, Chan LPS, Ho HF. Airway managed by emergency physicians or anaesthesiologists in trauma patients: A retrospective cohort analysis of outcomes. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920931719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: In some trauma centres, anaesthesiologists have the primary responsibility of managing airway in trauma resuscitation. However, as emergency physicians establish a separate specialty with airway management and endotracheal intubation being one of the core skills, role delineation within trauma members may vary. In this cohort study, we aim to determine the difference in mortality of trauma patients requiring intubation in the emergency department between emergency physicians and anaesthesiologists. Methods: We screened all 1588 patients in the hospital trauma registry from 2015 to 2018. We included all patients requiring endotracheal intubation and aged 18 or above but excluded those with pregnancy, presented with cardiac arrest and secondarily transferred from other hospitals. A total of 349 eligible patients were sorted into two cohorts according to the physicians who performed intubations (anaesthesiologists = 205 patients, emergency physicians = 144 patients). Patients’ baseline demographics, 30-day all-cause mortality and other predefined secondary outcomes were compared by statistical tests. Stepwise logistic regression of 30-day all-cause mortality was performed. Results: Our study has shown that intubation by emergency physicians was not associated with higher 30-day all-cause mortality after potential confounders were controlled by logistic regression (adjusted odds ratio = 1.253, p = 0.607). Both groups also did not differ in other clinical important secondary outcomes, including proportion of successful intubations, use of surgical airway or rescue manoeuvres, respiratory and airway complications, mortality in intensive care or high-dependency unit, post-intubation cardiac arrest, post-intubation hypotension and post-intubation hypoxia. Conclusion: Endotracheal intubation by emergency physicians is not associated with increased 30-day all-cause mortality when compared to anaesthesiologists after accounting for confounders.
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Affiliation(s)
- Tsz Ha Tang
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Marc LC Yang
- Accident and Emergency Department, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - On Yee Chan
- Accident and Emergency Department, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - Lily PS Chan
- Trauma Service, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - Hiu Fai Ho
- Accident and Emergency Department, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
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Luckscheiter A, Lohs T, Fischer M, Zink W. [Airway management in preclinical emergency anesthesia with respect to specialty and education]. Anaesthesist 2020; 69:170-182. [PMID: 32055885 DOI: 10.1007/s00101-020-00737-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/27/2019] [Accepted: 01/14/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Difficult airway management is a key skill in preclinical emergency medicine. A lower rate of subjective difficult airways and an increased success rate of endotracheal intubation have been reported for highly trained emergency physicians. The aim of this study was therefore to analyze the effect for different specialists and the individual state of training in the German emergency medical system. MATERIAL AND METHODS In a retrospective register analysis of 6024 preclinical anesthesia procedures, the frequencies of airway devices, neuromuscular blocking agents, capnography and difficult airways were analyzed with respect to specialization and status of training. Additionally, low, medium and highly experienced emergency physicians in airway management were summarized by specialization and status of training according to the Dreyfus model of skill acquisition and compared. RESULTS The incidence of subjective difficult airway situations was 10% for anesthesiological emergency physicians compared to 15-20% for other disciplines. The latter used supraglottic airway devices more often (7-9% vs. 4%) and video laryngoscopes less often (3% vs. 5%) compared to anesthesiological emergency physicians. The discipline-related state of training was inhomogeneous and revealed a reduced rate of supraglottic airway devices for internal specialists with further training (10% vs. 2%). Anesthetists specialized in intensive care medicine used capnography less frequently compared to other anesthetists (79% vs. 72%). With higher levels of experience in airway management, the frequency of endotracheal intubation (86% vs. 94%), neuromuscular blocking agents (59% vs. 73%) and video laryngoscopy (3% vs. 6%) increased and the incidence of subjective difficult airway situations (16% vs. 10%) decreased. CONCLUSION The level of training in airway management especially for non-anesthetists is inhomogeneous. The recently published German S1 guidelines for prehospital airway management recommend education and training as well as the primary use of the video laryngoscope with Macintosh blade. The implementation could lower the incidence of subjective difficult airways.
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Affiliation(s)
- A Luckscheiter
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen am Rhein, Deutschland.
| | - T Lohs
- Stelle zur trägerübergreifenden Qualitätssicherung im Rettungsdienst Baden-Württemberg (SQR-BW), Stuttgart, Deutschland
| | - M Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Alb Fils Kliniken, Göppingen, Deutschland
- Arbeitsgemeinschaft Südwestdeutscher Notärzte e. V. (AGSWN), Filderstadt, Deutschland
| | - W Zink
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen am Rhein, Deutschland
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Wahlen BM, El-Menyar A, Asim M, Al-Thani H. Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers. World J Emerg Med 2019; 10:19-26. [PMID: 30598714 PMCID: PMC6264984 DOI: 10.5847/wjem.j.1920-8642.2019.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/20/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND We aimed to describe the current practice of emergency physicians and anaesthesiologists in the selection of drugs for rapid-sequence induction (RSI) among trauma patients. METHODS A prospective survey audit was conducted based on a self-administered questionnaire among two intubating specialties. The preferred type and dose of hypnotics, opioids, and muscle relaxants used for RSI in trauma patients were sought in the questionnaire. Data were compared for the use of induction agent, opioid use and muscle relaxant among stable and unstable trauma patients by the intubating specialties. RESULTS A total of 102 participants were included; 47 were anaesthetists and 55 were emergency physicians. Propofol (74.5%) and Etomidate (50.0%) were the most frequently used induction agents. Significantly higher proportion of anesthesiologist used Propofol whereas, Etomidate was commonly used by emergency physicians in stable patients (P=0.001). Emergency physicians preferred Etomidate (63.6%) and Ketamine (20.0%) in unstable patients. The two groups were comparable for opioid use for stable patients. In unstable patients, use of opioid differed significantly by intubating specialties. The relation between rocuronium and suxamethonium use did change among the anaesthetists. Emergency physicians used more suxamethonium (55.6% vs. 27.7%, P=0.01) in stable as well as unstable (43.4 % vs. 27.7%, P=0.08) patients. CONCLUSION There is variability in the use of drugs for RSI in trauma patients amongst emergency physicians and anaesthesiologists. There is a need to develop an RSI protocol using standardized types and dose of these agents to deliver an effective airway management for trauma patients.
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Affiliation(s)
| | - Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
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Han MJ, Lee JR, Shin YJ, Son JS, Choi EJ, Oh YH, Lee SH, Choi HR. Effects of a simulated emergency airway management education program on the self-efficacy and clinical performance of intensive care unit nurses. Jpn J Nurs Sci 2018; 15:258-266. [PMID: 29271060 DOI: 10.1111/jjns.12195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 11/30/2022]
Abstract
AIM To examine the effects of a simulated emergency airway management education program on the self-efficacy and clinical performance among nurses in intensive care units. METHODS A one-group, pre- and post-test design was used. Thirty-five nurses who were working in adult intensive care units participated in this study. The simulation education program included lectures, skill demonstration, skill training, team-based practice, and debriefing. Self-efficacy and clinical performance questionnaires were completed before the program and 1 week after its completion. The data were analyzed by using descriptive statistics and the paired t-test to compare the mean differences between the pre-test and post-test. The scores before and after education were compared. RESULTS After education, there was a significant improvement in the nurses' self-efficacy and clinical performance in emergency airway management situations. CONCLUSION Simulation education effectively improved the self-efficacy and clinical performance of the nurses who were working in intensive care units. Based on the program for clinical nurses within a hospital, it will provide information that might advance clinical nursing education.
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Affiliation(s)
- Myong-Ja Han
- Medical Alert Team, Asan Medical Center, Seoul, South Korea
| | - Ju-Ry Lee
- Medical Alert Team, Asan Medical Center, Seoul, South Korea
| | - Yu-Jung Shin
- Medical Alert Team, Asan Medical Center, Seoul, South Korea
| | - Jeong-Suk Son
- Medical Alert Team, Asan Medical Center, Seoul, South Korea
| | - Eun-Joo Choi
- Medical Alert Team, Asan Medical Center, Seoul, South Korea
| | - Yun-Hee Oh
- Simulation Center, Asan Medical Center, Seoul, South Korea
| | - Soon-Haeng Lee
- Department of Performance Improvement, Asan Medical Center, Seoul, South Korea
| | - Hye-Ran Choi
- Department of Clinical Nursing, University of Ulsan College of Medicine, Seoul, South Korea
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Patient-specific Factors Associated with Difficult Mask Ventilation in the Emergency Department. INT J GERONTOL 2017. [DOI: 10.1016/j.ijge.2017.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Takeuchi S, Shiga T, Koyama Y, Nakanishi T, Honma Y, Morita H, Goto T. Longitudinal acquisition of endotracheal intubation skills in novice physicians. PLoS One 2017; 12:e0188224. [PMID: 29136003 PMCID: PMC5685566 DOI: 10.1371/journal.pone.0188224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/02/2017] [Indexed: 11/18/2022] Open
Abstract
Little is known about the acquisition of intubation skills among novice physicians during their one-year clinical training. Our primary objective was to determine the changes in the intubation skills of novice physicians between prior to the clinical training and after completion of the clinical training. We used data of a prospective longitudinal multicenter data registry developed to investigate factors associated with the improvement of intubation skills among novice physicians. The study participants included 90 postgraduate year 1 physicians in 2015–2016. We used 4 simulation scenarios based on the devices used (direct laryngoscope [DL] and Airway scope [AWS]) and difficulty of intubation (normal and difficult scenarios). As a marker of the intubation skills, we used the force applied on the maxillary incisors and the tongue with each intubation. We compared the data obtained prior to clinical training with those obtained after completion of one-year clinical training. When using DL, compared to prior, significantly less force were applied on the maxillary incisors and the tongue after clinical training in the normal scenario (28.0 N vs 19.5 N, p < 0.001, and 11.1 N vs 8.4 N, p = 0.004). Likewise, when using AWS, compared to prior, significantly less force were applied on the tongue after clinical training in the normal scenario (22.0 N vs 0 N, p < 0.001). The force on the tongue decreased after clinical training but not significant. These associations persisted in the difficult airway scenario. These findings suggest that force applied on oral structures can be quantified as a marker of intubation skills by using high-fidelity simulators, and the assessment of procedural competency is recommended for all novice physicians prior to performing intubation in the clinical setting to improve the quality of emergency care.
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Affiliation(s)
- Shinya Takeuchi
- Department of Emergency Medicine, Teikyo University, Itabashi, Japan
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
- * E-mail:
| | - Takashi Shiga
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
- Department of Emergency Medicine, International University of Health and Welfare, Minato, Japan
| | - Yasuaki Koyama
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Taizo Nakanishi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Yosuke Honma
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Hiroshi Morita
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Sakles JC, Corn GJ, Hollinger P, Arcaris B, Patanwala AE, Mosier JM. The Impact of a Soiled Airway on Intubation Success in the Emergency Department When Using the GlideScope or the Direct Laryngoscope. Acad Emerg Med 2017; 24:628-636. [PMID: 28109012 DOI: 10.1111/acem.13160] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/01/2017] [Accepted: 01/14/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND The objective was to determine the impact of a soiled airway on firstpass success when using the GlideScope video laryngoscope or the direct laryngoscope for intubation in the emergency department (ED). METHODS Data were prospectively collected on all patients intubated in an academic ED from July 1, 2007, to June 30, 2016. Patients ≥ 18 years of age, who underwent rapid sequence intubation by an emergency medicine resident with the GlideScope or the direct laryngoscope, were included in the analysis. Data were stratified by device used (GlideScope or direct laryngoscope). The primary outcome was firstpass success. Patients were categorized as those without blood or vomitus (CLEAN) and those with blood or vomitus (SOILED) in their airway. Multivariate regression models were developed to control for confounders. RESULTS When using the GlideScope, the firstpass success was lower in the SOILED group (249/306; 81.4%) than the in CLEAN group (586/644, 91.0%; difference = 9.6%; 95% confidence interval [CI] = 4.7%-14.5%). Similarly, when using the direct laryngoscope, the firstpass success was lower in the SOILED group (186/284, 65.5%) than in the CLEAN group (569/751, 75.8%; difference = 10.3%; 95% CI = 4.0%-16.6%). The SOILED airway was associated with a decreased firstpass success in both the GlideScope cohort (adjusted odds ratio [aOR] = 0.4; 95% CI = 0.3-0.7) and the direct laryngoscope cohort (aOR = 0.6; 95% CI = 0.5-0.8). CONCLUSION Soiling of the airway was associated with a reduced firstpass success during emergency intubation, and this reduction occurred to a similar degree whether using either the GlideScope or the direct laryngoscope.
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Affiliation(s)
- John C. Sakles
- Department of Emergency Medicine; The University of Arizona College of Medicine; Tucson AZ
| | - G. Judson Corn
- Department of Emergency Medicine; The University of Arizona College of Medicine; Tucson AZ
| | - Patrick Hollinger
- Department of Emergency Medicine; The University of Arizona College of Medicine; Tucson AZ
| | | | - Asad E. Patanwala
- Department of Pharmacy Practice and Science; The University of Arizona College of Pharmacy; Tucson AZ
| | - Jarrod M. Mosier
- Department of Emergency Medicine; The University of Arizona College of Medicine; Tucson AZ
- Department of Medicine; Section of Pulmonary, Critical Care, Allergy and Sleep; The University of Arizona College of Medicine; Tucson AZ
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Limbach T, Ott T, Griesinger J, Jahn-Eimermacher A, Piepho T. Bonfils intubation fibrescope: use in simulation-based intubation training for medical students in comparison to MacIntosh laryngoscope. BMC Res Notes 2016; 9:127. [PMID: 26920895 PMCID: PMC4769496 DOI: 10.1186/s13104-016-1937-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/15/2016] [Indexed: 11/10/2022] Open
Abstract
Background A variety of instruments are used to perform airway management by tracheal intubation. In this study, we compared the MacIntosh balde (MB) laryngoscope with the Bonfils intubation fibrescope as intubation techniques. The aim of this study was to identify the technique (MB or Bonfils) that would allow students in their last year of medical school to perform tracheal intubation faster and with a higher success probability. Data were collected from 150 participants using an airway simulator [‘Laerdal Airway Management Trainer’ (Laerdal Medical AS, Stavanger, Norway)]. The participants were randomly assigned to a sequence of techniques to use. Four consecutive intubation ‘trials’ were performed with each technique. These trials were evaluated for differences in the following categories: the ‘time to successful ventilation‘, ‘success probability’ within 90 s,’time to visualisation’ of the vocal cords (glottis), and ‘quality of visualisation’ according to the Cormack and Lehane score (C&L, grade 1–4). The primary endpoint was the ‘time to successful ventilation‘in the fourth and final trial. Results There was no statistically significant difference in the ‘time to successful ventilation’ between the two techniques in trial 4 (‘time to successful ventilation’: median: MB: 16 s, Bonfils: 14 s, p = 0.244). However, the ‘success probability’ within 90 s was higher when using a Macintosh blade than when using a Bonfils (95 vs. 87 %). The glottis could be better visualised when using a Bonfils (C&L score of 1 (best view): MB: 41 %, Bonfils: 93 %), but visualisation was achieved more rapidly when using a Macintosh blade (median: ‘time to visualisation’: MB: 6 s, Bonfils: 8 s, p = 0.003). Conclusions The time to ventilation using the MacIntosh blade and Bonfils mainly did to differ, however success probabilities and time to visualisation primary favoured the MacIntosh blade as intubation technique, although the Bonfils seem to have a steeper learning curve. The Bonfils is still a promising intubation technique and might be easier to learn as the MB, at least in a manikin. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-1937-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tobias Limbach
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Langenbeckstr 1, Mainz, 55131, Germany.
| | - Thomas Ott
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Langenbeckstr 1, Mainz, 55131, Germany.
| | - Jan Griesinger
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Langenbeckstr 1, Mainz, 55131, Germany.
| | - Antje Jahn-Eimermacher
- Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstr 1, Mainz, 55131, Germany.
| | - Tim Piepho
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Langenbeckstr 1, Mainz, 55131, Germany.
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Prevalence and outcomes of endotracheal intubation–related cardiac arrest in the ED. Am J Emerg Med 2015; 33:1642-5. [DOI: 10.1016/j.ajem.2015.07.083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 11/18/2022] Open
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Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach. BIOMED RESEARCH INTERNATIONAL 2015; 2015:724032. [PMID: 26161411 PMCID: PMC4486512 DOI: 10.1155/2015/724032] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/10/2015] [Indexed: 11/17/2022]
Abstract
According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients.
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Kim WY, Kwak MK, Ko BS, Yoon JC, Sohn CH, Lim KS, Andersen LW, Donnino MW. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One 2014; 9:e112779. [PMID: 25402500 PMCID: PMC4234501 DOI: 10.1371/journal.pone.0112779] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 10/14/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED). The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication. METHODS A matched case-control study with a case to control ratio of 1:3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities. RESULTS Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7%) had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%). Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001). Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤ 90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58-8.55], p = 0.01). CONCLUSION Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation.
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Affiliation(s)
- Won Young Kim
- Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Korea
- Department of Emergency Medicine, Seoul Medical Center, Seoul, Korea
- * E-mail:
| | - Myoung Kwan Kwak
- Department of Emergency Medicine, Seoul Medical Center, Seoul, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Chol Yoon
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Korea
| | - Lars W. Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael W. Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
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Lee MJ, Jung D. The Impact of a Simulation-based Education Program for Emergency Airway Management on Self-efficacy and Clinical Performance among Nurses. ACTA ACUST UNITED AC 2014. [DOI: 10.7475/kjan.2014.26.1.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Mi-Ja Lee
- Graduate School, Ewha Womans University, Seoul, Korea
| | - Dukyoo Jung
- Division of Nursing Science, College of Health Sciences, Ewha Womans University, Seoul, Korea
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The usefulness of 3-dimensional virtual simulation using haptics in training orotracheal intubation. BIOMED RESEARCH INTERNATIONAL 2013; 2013:534097. [PMID: 24163817 PMCID: PMC3791581 DOI: 10.1155/2013/534097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 08/21/2013] [Indexed: 11/20/2022]
Abstract
Objectives. Airway control is the most critical treatment. The most common and basic method of endotracheal intubation is orotracheal intubation. To perform accurate and rapid tracheal intubation, appropriate education and training are required. We developed the virtual simulation program utilizing the 3-dimensional display and haptic device to exercise orotracheal intubation, and the educational effect of this program was compared with that of the mannequin method. Method. The control group used airway mannequin and virtual intubation group was trained with new program. We videotaped both groups during objective structured clinical examination (OSCE) with airway mannequin. The video was reviewed and scored, and the rate of success and time were calculated. Result. The success rate was 78.6% in virtual intubation group and 93.3% in control group (P = 0.273). There was no difference in overall score of OSCE (21.14 ± 4.28 in virtual intubation group and 23.33 ± 4.45 in control group, P = 0.188), the time spent in successful intubation (P = 0.432), and the number of trials (P > 0.101). Conclusion. The virtual simulation with haptics had a similar effect compared with mannequin, but it could be more cost effective and convenient than mannequin training in time and space.
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22
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Evaluation of the association between postintubation hypotension and lidocaine administered as a premedication for rapid sequence intubation: A comparison between traditional regression methods and propensity score matching-based method. J Acute Med 2013. [DOI: 10.1016/j.jacme.2013.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Varga S, Shupp JW, Maher D, Tuznik I, Sava JA. Trauma airway management: transition from anesthesia to emergency medicine. J Emerg Med 2013; 44:1190-5. [PMID: 23473818 DOI: 10.1016/j.jemermed.2012.11.074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 10/21/2012] [Accepted: 11/18/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Trauma airway management is commonly performed by either anesthesiologists or Emergency Physicians (EPs). OBJECTIVE Our aim was to evaluate the impact of switching from one group of providers to the other, focusing on outcomes and complications. METHODS Medical records were used to identify all patients during a 3-year period who were intubated emergently after traumatic injury. Before November 1, 2007, airway management was supervised by anesthesiologists, after that date airways were supervised by EPs. Complications evaluated included failure to obtain a secure airway, multiple attempts at airway placement, new or worsening hypoxia or hypotension during the peri-intubation period, bronchial intubations, dysrhythmia, aspiration with development of infiltrate on chest x-ray study within 48 h, and facial trauma. RESULTS Of the 490 tracheal intubations, 250 were attended by EPs and 240 were attended by anesthesiologists. The groups were well matched with respect to age and sex, but the EP group treated more severely injured patients on average. Intubation was accomplished in one attempt 98.3% of the time in the anesthesia group; those requiring multiple attempts went on to need surgical airways 2.1% of the time. EPs accomplished intubation in one attempt 98.4% of the time, with an overall success rate of 96.8%; surgical airways were needed in 3.2% of patients. The complication rate was 18.3% for the anesthesia group and 18% for the EP group. There were no statistically significant differences between the EP and anesthesia groups with regard to complication rates, although the EP patients had a higher Injury Severity Score on average. CONCLUSIONS EPs can safely manage the airways of trauma patients with rates of complication and failure comparable with those of anesthesiologists.
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Affiliation(s)
- Stephen Varga
- Division of Trauma and Surgical Critical Care, USC Department of Surgery, University of Southern California, LAC + USC Medical Center, Los Angeles, CA 90033, USA
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Garcia A, Yeung LY, Miraflor EJ, Victorino GP. Should Uncooperative Trauma Patients with Suspected Head Injury be Intubated? Am Surg 2013. [DOI: 10.1177/000313481307900333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In trauma patients with a suspicion for traumatic brain injury (TBI), a head computed tomography (CT) scan is imperative. However, uncooperative patients often cannot undergo imaging without sedation and may need to be intubated. Our hypothesis was that among mildly injured trauma patients, in whom there is a suspicion of a head injury, uncooperative patients have higher rates of TBI and intubation should be considered to obtain a CT scan. We found that uncooperative patients intubated for diagnostic purposes were more likely to have moderate to severe TBI than nonintubated patients (21.4 vs 8.4%, P < 0.0001) and uncooperative behavior leading to intubation was an independent predictor of TBI (odds ratio, 2.5; 95% confidence interval, 1.5 to 4.5). Of patients with brain injury, intubated patients more often had a head Abbreviated Injury Scale score of 4 (20.8 vs 7.9%, P = 0.04). Uncooperative intubated patients had longer hospital stays (3.6 vs 2.6 days, P = 0.003) and higher mortality (0.9 vs 0.2%, P = 0.02) than nonintubated patients. Uncooperative behavior may be an early warning sign of TBI and the trauma surgeon should consider intubating uncooperative trauma patients if there is suspicion for brain injury based on the mechanism of their trauma.
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Green RS, Edwards J, Sabri E, Fergusson D. Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability. CAN J EMERG MED 2012; 14:74-82. [PMID: 22554438 DOI: 10.2310/8000.2012.110548] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine. METHODS A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≤ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation. RESULTS Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01-1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19-7.57), and pre-emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27-4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16-0.75). CONCLUSIONS Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.
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Affiliation(s)
- Robert S Green
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
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Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial. Can J Anaesth 2012; 59:1032-9. [PMID: 22932944 DOI: 10.1007/s12630-012-9775-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 08/16/2012] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers. METHODS Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures. RESULTS Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04). CONCLUSIONS Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.
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Paul AM, Young NH, Price GC. Emergency tracheal intubation without drugs: outcome and one-year survival of medical patients not in cardiac arrest. Scott Med J 2012; 57:84-7. [PMID: 22555228 DOI: 10.1258/smj.2012.012005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Non-medicine-assisted tracheal intubation in prehospital trauma is associated with a dismal prognosis. We wished to study the outcome of medical patients who underwent non-medicine-assisted tracheal intubation. This retrospective study of patients attending our university hospital emergency department was conducted over seven years. The tracheal intubation database was analysed to identify medical patients not in cardiac arrest undergoing tracheal intubation without medicines. Intensive care unit, hospital, 12-month mortality and patients' residence at 12 months were recorded. Eighty patients were identified who met inclusion criteria. The most common reason for intubation was definite airway compromise due to decreased conscious level (62.5%), then respiratory failure (26.3%) and finally potentially compromised airway due to a decreased conscious level (11.2%). Eighty-eight percent of patients with a definitely compromised airway were successfully intubated at first attempt compared with 66.7% of patients with a potentially compromised airway or respiratory failure (P= 0.03). Of 75 patients with complete data, 30 (40%) were survivors at 12 months, with all but two (6.7%) living at home. Non-medicine-assisted laryngoscopy leads to an increased first time tracheal intubation failure rate in patients with intact airway reflexes and, therefore, cannot be recommended as best practice.
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Affiliation(s)
- A M Paul
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
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Kim MH, Oh AY, Jeon YT, Hwang JW, Do SH. A randomised controlled trial comparing rocuronium priming, magnesium pre-treatment and a combination of the two methods. Anaesthesia 2012; 67:748-54. [PMID: 22420830 DOI: 10.1111/j.1365-2044.2012.07102.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We investigated whether magnesium sulphate combined with rocuronium priming shortens the onset of neuromuscular blockade, compared with these methods used alone. Ninety-two patients scheduled for general anaesthesia were randomly allocated to one of four groups: controls were given 0.6 mg.kg(-1) rocuronium; patients in the prime group were given 0.06 mg.kg(-1) rocuronium three minutes before a further dose of 0.54 mg.kg(-1) rocuronium; patients in the magnesium group were given an infusion of 50 mg.kg(-1) magnesium sulphate before rocuronium and patients in the magnesium and prime group were given both the magnesium sulphate and the priming dose of rocuronium. Tracheal intubation was attempted 40 s after the rocuronium injection. The time to onset of neuromuscular blockade was the primary outcome; duration of blockade and tracheal intubating conditions were also measured. The group allocation and study drugs were coded and concealed until statistical analyses were completed. The magnesium and prime group had the shortest mean (SD) onset time (55 (16)s; p < 0.001), and best tracheal intubating conditions (p < 0.05). No statistical difference was found for the duration of blockade. As for adverse events, a burning or heat sensation was reported in eight (35%) and six (26%) patients in the magnesium and magnesium and prime groups, respectively. The combination of magnesium sulphate and rocuronium priming accelerated the onset or neuromuscular blockade and improved rapid-sequence intubating conditions, compared with either magnesium sulphate or priming used alone.
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Affiliation(s)
- M H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University, South Korea
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Gangadharan L, Sreekanth C, Vasnaik MC. Prediction of difficult intubations using conventional indicators: Does rapid sequence intubation ease difficult intubations? A prospective randomised study in a tertiary care teaching hospital. J Emerg Trauma Shock 2011; 4:42-7. [PMID: 21633566 PMCID: PMC3097578 DOI: 10.4103/0974-2700.76836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 09/17/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Endotracheal intubations performed in the Emergency Department. AIMS To assess whether conventional indicators of difficult airway can predict a difficult intubation in the Emergency Setting and to investigate the effect of rapid sequence intubation (RSI) on ease of intubation. SETTINGS AND DESIGN A prospective randomized study was designed involving 60 patients requiring intubation, over a period of 4 months. MATERIALS AND METHODS Demographic profile, details of methods used, airway assessment, ease of intubation, and Cormack and Lehane score were recorded. Airway assessment score and ease of intubation criteria were devised and assessed. STATISTICAL ANALYSIS Descriptive statistical analysis was carried out. Chi-square/2 × 2, 2 × 3, 3 × 3, Fisher Exact test have been used to find the significance of study parameters on categorical scale between two or more groups. RESULTS Patients with a Mallampatti score of three or four were found to have worse laryngoscopic views (Cormack-Lehane score, 3 or 4). Of all airway indicators assessed, an increased Mallampatti score was found to have significant correlation with increased difficulty in intubation. The use of RSI was associated with better laryngoscopic views, and easier intubations. CONCLUSIONS An airway assessment using the Mallampatti score is invaluable as a tool to predict a difficult airway and should be performed routinely if possible. RSI aids intubation ease. If not otherwise contraindicated, it should be performed routinely for all intubations in the ED.
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Affiliation(s)
- Lakshmi Gangadharan
- Department of Emergency Medicine, St. Johns' Medical College and Hospital, Bangalore, India
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The Easytube for airway management in prehospital emergency medicine. Resuscitation 2011; 81:1516-20. [PMID: 20621409 DOI: 10.1016/j.resuscitation.2010.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 04/19/2010] [Accepted: 06/02/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Securing the airway in emergency is among the key requirements of appropriate prehospital therapy. The Easytube (Ezt) is a relatively new device, which combines the advantages of both an infraglottic and supraglottic airway. AIMS Our goal was to evaluate the effectiveness and the safety of use of Ezt by emergency physicians in case of difficult airway management in a prehospital setting with minimal training. METHODS We performed a prospective multi-centre observational study of patients requiring airway management conducted in prehospital emergency medicine in France by 3 French mobile intensive care units from October 2007 to October 2008. RESULTS Data were available for 239 patients who needed airway management. Two groups were individualized: the "easy airway management" group (225 patients; 94%) and the "difficult airway management" group (14 patients; 6%). All patients had a successful airway management. The Ezt was used in eight men and six women; mean age was 64 years. It was used for ventilation for a maximum of 150 min and the mean time was 65 min. It was positioned successfully at first attempt, except for two patients, one needed an adjustment because of an air leak, and in the other patient the Ezt was replaced due to complete obstruction of the Ezt during bronchial suction. CONCLUSION The present study shows that emergency physicians in cases of difficult airway management can use the EzT safely and effectively with minimal training. Because of its very high success rate in ventilation, the possibility of blind intubation, the low failure rate after a short training period. It could be introduced in new guidelines to manage difficult airway in prehospital emergency.
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Corso RM, Gambale G, Piraccini E, Petrini F. Emergency airway management using the Bonfils intubation fiberscope. Intern Emerg Med 2010; 5:447-9. [PMID: 20221809 DOI: 10.1007/s11739-010-0366-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 02/13/2010] [Indexed: 11/26/2022]
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Winton J, Celenza A, Jackson T. Improving documentation of endotracheal intubation in an adult emergency department. Emerg Med Australas 2010; 20:488-93. [PMID: 19125827 DOI: 10.1111/j.1742-6723.2008.01134.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the effect of an educational intervention and documentary pro forma on the adequacy of documentation of intubation in an adult ED. METHODS A structured medical record review was performed before and after a multi-pronged educational programme and introduction of a specifically designed guide to documentation. Records were assessed for adequacy of documentation by the presence or absence of predetermined elements. Analysis focused on five aspects considered to be most important for future clinical care: drugs and doses used, grade of view, size of endotracheal tube, confirmation of placement and adverse events/difficulties encountered. RESULTS Sixty-one and sixty-eight charts were included in the pre-intervention and post-intervention groups, respectively. The drugs and doses used were documented in 92% and 93%. The endotracheal tube size was recorded 82% and 91% of the time. Grade of laryngoscopy was documented in 35% and 46%. Confirmation of endotracheal tube placement was 69% and 84%. Presence or absence of adverse events was recorded in 37% and 54%. All five elements were present in 8.2% and 25% of medical records. CONCLUSION Documentation improved slightly following the intervention, but was still unsatisfactory. We believe that to achieve an adequate level of documentation in the medical record for an episode of intubation, there needs to be a formal and structured mechanism, either via mandatory use of a specifically designed form and/or by participation in an organized data registry.
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Affiliation(s)
- James Winton
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Hospital Outcomes and Disposition of Trauma Patients Who Are Intubated Because of Combativeness. ACTA ACUST UNITED AC 2010; 68:1305-9. [DOI: 10.1097/ta.0b013e3181dcd137] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Phelan MP, Glauser J, Yuen HWA, Sturges-Smith E, Schrump SE. Airway Registry: A Performance Improvement Surveillance Project of Emergency Department Airway Management. Am J Med Qual 2010; 25:346-50. [DOI: 10.1177/1062860610366590] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: coping with the difficult airway. World J Emerg Surg 2009; 4:21. [PMID: 19473497 PMCID: PMC2693512 DOI: 10.1186/1749-7922-4-21] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 05/27/2009] [Indexed: 12/12/2022] Open
Abstract
Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.
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Affiliation(s)
- Amir A Krausz
- Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Imad Abu El-Naaj
- Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Michal Barak
- Department of Anesthesiology, Rambam Health Care Campus, and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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García-Aguado R. [Has everything been said about the difficult airway? Other points of view are possible]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:269-272. [PMID: 19580128 DOI: 10.1016/s0034-9356(09)70392-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Mace SE. Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am 2009; 26:1043-68, x. [PMID: 19059100 DOI: 10.1016/j.emc.2008.10.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.
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Affiliation(s)
- Sharon Elizabeth Mace
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve, Cleveland, OH 44195, USA.
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The prognostic factors of hypotension after rapid sequence intubation. Am J Emerg Med 2008; 26:845-51. [DOI: 10.1016/j.ajem.2007.11.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 11/14/2007] [Accepted: 11/14/2007] [Indexed: 11/21/2022] Open
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The difficult airway in the emergency department. Int J Emerg Med 2008; 1:107-11. [PMID: 19384660 PMCID: PMC2657243 DOI: 10.1007/s12245-008-0030-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 04/29/2008] [Indexed: 11/10/2022] Open
Abstract
Background The patient with difficult airways is a common challenge for emergency physicians. Aims Our goal was to study the reasons for difficult airways in the emergency department. Methods We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006. Results There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope. Conclusions Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.
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Aghdashi MM, Abassivash R, Hassani E. Intralingual tracheal intubation! ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2007; 26:889-90. [PMID: 17693050 DOI: 10.1016/j.annfar.2007.07.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Corfield AR, Thomas L, Inglis A, Hearns S. A rural emergency medical retrieval service: the first year. Emerg Med J 2007; 23:679-83. [PMID: 16921078 PMCID: PMC2564207 DOI: 10.1136/emj.2006.034355] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION We describe the first year of operation of a rural emergency medical retrieval service (EMRS), staffed by emergency medicine and anaesthetic consultants and providing air based retrieval of critically ill and injured patients from general practitioner led community hospitals in rural west Scotland. METHODS Data were collected on all patients referred to the service, both those subsequently transported and those where transport by the service was not indicated, for a period of 1 year from 1 October 2004 to 30 September 2005. Data collected included information on demographics, physiology, and medical interventions. Detailed data were collected regarding advanced airway care and any complications relating to transfer. RESULTS Forty patients were attended and advice was given on a further 21 patients. Twenty one of the 40 patients (53%) required rapid sequence intubation prior to transfer. The median Injury Severity Score (ISS) for trauma patients was 26 (range 2-59). The median Acute Physiology and Chronic Health Evaluation (APACHE) II score for all patients was 11 (range 2-37). CONCLUSION Our data show a high level of acuity among this patient group and a need for advanced medical intervention to ensure safe transfer.
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Affiliation(s)
- A R Corfield
- Emergency Medicine, Royal Alexandra Hospital, Paisley, PA2 9PN, UK.
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Simpson J, Munro PT, Graham CA. Rapid sequence intubation in the emergency department: 5 year trends. Emerg Med J 2006; 23:54-6. [PMID: 16373805 PMCID: PMC2564130 DOI: 10.1136/emj.2004.019398] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM Airway management is a core aspect of emergency medicine. The technique of rapid sequence intubation (RSI) creates continuing debate between anaesthetists and emergency physicians in the UK, although similar complication rates for emergency department (ED) RSI have been shown for both specialties. This study examined prospectively collected data on every ED RSI performed in a university hospital in Glasgow over 5 years. METHODS Data were prospectively recorded for every attempted RSI in the ED on a dedicated form (as used in previous studies) between January 1999 and December 2003. Immediate complications were specifically sought in the questionnaire, as was the immediate destination on leaving the ED. The chi2 test was used for categorical data. RESULTS On average, 51 ED RSI were performed annually (range 42-60). Emergency physician RSI for trauma increased from 32% (7/22) in 1999 to 75% (21/28) in 2003 (chi2 = 9.32, df = 1, p = 0.002) and for non-trauma from 62% (18/29) in 1999 to 79% (23/29) in 2003 (chi2 = 2.08, df = 1, p = 0.15). Complication rates for emergency physician RSI decreased from 43% (3/7) to 14% (3/21) for trauma (chi2 = 2.55, df = 1, p = 0.11) and from 28% (5/18) to 4% (1/23) for non-trauma (chi2 = 4.44, df = 1, p = 0.035). This compares with mean complication rates for anaesthetists for trauma of 17% and for non-trauma of 22%. Incidence of hypotension decreased in all groups; however, oxygen desaturation is now the most common complication. The rate of ED RSI prior to computed tomography (CT) scans increased in both the trauma (79% v 42%; chi2 = 7.42, df = 1, p = 0.0065) and non-trauma (48% v 17%; chi2 = 5.85, df = 1, p = 0.016) groups. CONCLUSION Emergency physician performed ED RSI is increasingly common but is not associated with overall higher numbers of RSIs being performed in the ED. Effective pre-oxygenation should be emphasised during training.
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Affiliation(s)
- J Simpson
- Emergency Department, Southern General Hospital, Glasgow G51 4TF, UK
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Ollerton JE, Parr MJA, Harrison K, Hanrahan B, Sugrue M. Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review. Emerg Med J 2006; 23:3-11. [PMID: 16373795 PMCID: PMC2564122 DOI: 10.1136/emj.2004.020552] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Revised: 12/21/2004] [Accepted: 02/04/2005] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. OBJECTIVES To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. SEARCH STRATEGY AND METHODOLOGY Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.
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Affiliation(s)
- J E Ollerton
- Department of Trauma, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia.
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Neilipovitz DT, Lim M, Celaschi DA. Rapid sequence intubation: how do we define success? Can J Anaesth 2004. [DOI: 10.1007/bf03018473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Law JA, Kovacs G. Reply. Can J Anaesth 2004. [DOI: 10.1007/bf03018474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Labrecque P. L’intubation trachéale hors du bloc opératoire. Can J Anaesth 2004; 51:106-10. [PMID: 14766683 DOI: 10.1007/bf03018766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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