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Weingart SD, Barnicle RN, Janke A, Bhagwan SD, Tanzi M, McKenna PJ, Bracey A. A taxonomy of key performance errors for emergency intubation. Am J Emerg Med 2023; 73:137-144. [PMID: 37657143 DOI: 10.1016/j.ajem.2023.08.035] [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: 02/05/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/03/2023] Open
Abstract
STUDY OBJECTIVE Currently the videographic review of emergency intubations is an unstructured, qualitative process. We created a taxonomy of errors that impede the optimal procedural performance of emergency intubation. METHODS This was a prospective, observational, study reviewing a convenience sample of deidentified laryngoscopy recordings of emergency department intubations that were qualitatively flagged before the study as demonstrating suboptimal technique. These videos were coded for the presence of 13 predetermined performance errors. Our primary outcome was the incidence of each of these specified errors during emergency intubation. Errors fell into 3 categories: errors of structure recognition during laryngoscope insertion, errors of vallecula manipulation, and errors of device delivery. RESULTS A total of 100 intubation attempts were reviewed. The most common error was inadequate lifting force with the blade tip in the vallecula which lowered the percent of glottic opening, occurring in 45% of the attempts. The least common performance error was the premature removal of the laryngoscope during bougie placement, occurring in only 9% of the videos. CONCLUSION We developed a taxonomy of 13 performance errors of laryngoscopy. Further study is warranted to determine how to best incorporate these into emergency airway training and the airway review process.
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Affiliation(s)
- Scott D Weingart
- Nassau University Medical Center, Department of Emergency Medicine, East Meadow, NY, USA.
| | - Ryan N Barnicle
- Yale New Haven Hospital, Department of Emergency Medicine, New Haven, CT, USA
| | - Alexander Janke
- Yale New Haven Hospital, Department of Emergency Medicine, New Haven, CT, USA
| | - Sabrina D Bhagwan
- Elmhurst Hospital Center, Department of Anesthesia, Elmhurst, NY, USA
| | - Matthew Tanzi
- Stony Brook University Medical Center, Department of Emergency Medicine, Stony Brook, NY, USA
| | - Peter J McKenna
- Stony Brook University Medical Center, Department of Emergency Medicine, Stony Brook, NY, USA
| | - Alexander Bracey
- Albany Medical Center, Department of Emergency Medicine, Albany, NY, USA
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Perkins EJ, Begley JL, Brewster FM, Hanegbi ND, Ilancheran AA, Brewster DJ. The use of video laryngoscopy outside the operating room: A systematic review. PLoS One 2022; 17:e0276420. [PMID: 36264980 PMCID: PMC9584394 DOI: 10.1371/journal.pone.0276420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/12/2022] [Indexed: 11/07/2022] Open
Abstract
This study aimed to describe how video laryngoscopy is used outside the operating room within the hospital setting. Specifically, we aimed to summarise the evidence for the use of video laryngoscopy outside the operating room, and detail how it appears in current clinical practice guidelines. A literature search was conducted across two databases (MEDLINE and Embase), and all articles underwent screening for relevance to our aims and pre-determined exclusion criteria. Our results include 14 clinical practice guidelines, 12 interventional studies, 38 observational studies. Our results show that video laryngoscopy is likely to improve glottic view and decrease the incidence of oesophageal intubations; however, it remains unclear as to how this contributes to first-pass success, overall intubation success and clinical outcomes such as mortality outside the operating room. Furthermore, our results indicate that the appearance of video laryngoscopy in clinical practice guidelines has increased in recent years, and particularly through the COVID-19 pandemic. Current COVID-19 airway management guidelines unanimously introduce video laryngoscopy as a first-line (rather than rescue) device.
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Affiliation(s)
| | - Jonathan L. Begley
- Alfred Health, Melbourne, VIC, Australia
- Intensive Care Unit, Cabrini Hospital, Malvern, VIC, Australia
| | - Fiona M. Brewster
- Department of Anaesthesia, Royal Women’s Hospital, Parkville, VIC, Australia
| | | | | | - David J. Brewster
- Intensive Care Unit, Cabrini Hospital, Malvern, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
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Liu HH, Wang Y, Zhong M, Li YH, Gao H, Zhang JF, Ma WH. Managing the difficult airway: A survey of doctors with different seniority in China. Medicine (Baltimore) 2021; 100:e27181. [PMID: 34559107 PMCID: PMC8462557 DOI: 10.1097/md.0000000000027181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Although equipment and human resources are vital elements of difficult airway management (DAM). But the approach and practice of DAM are more important. So, we conducted the present survey to address anesthesiologists of different working years in this knowledge gap.This nationwide cross-sectional study was conducted from October 27, 2016 to November 27, 2016. The survey was completed online in New Youth Anesthesia Forum including DAM assessment, anticipated and unanticipated DAM, difficult airway algorithm, use of the front of neck access (FONA) technique and training, DAM outside the operation room, and difficult extubation management.We received 1935 replies (44%). Mouth opening and Mallampati classification were the most common methods to evaluate difficult airways. When suffering from unanticipated difficult airway 63% less than 10 years anesthesiologists (LA) and 65% more than 10 years anesthesiologists (MA) would ask for help after trying 1 to 2 times (P = .000). More than 70% of LA and MA respondents reported preferring cannula cricothyrotomy to deal with emergency airway, 507 (41.6%) MA respondents reported that they used FONA techniques to save patients' lives (P = .000). Nearly 70% respondents worried full stomach when intubated outside operation room and more than 80% respondents selected auscultation to identify the placement. More than 80% respondents had not used Bougie to assist extubation. A 73.2% respondents know ABS algorithm and 96.4% know Chinese airway expert consensus among MA respondents, this was significant to LA respondents (P = .000).The respondents in the LA and MA have a training gap in their evaluation of difficult airways, trained and used FONA emergency skills, facilitated of the airway guidelines at home and abroad. Also, we should provide more airway theory and skill training to our young doctors to advanced airway skills.
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Affiliation(s)
- Hui-Hui Liu
- Department of Anesthesiology, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, P.R. China
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, P.R. China
| | - Yong Wang
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, P.R. China
| | - Ming Zhong
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, P.R. China
| | - Yu-Hui Li
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, P.R. China
| | - Huan Gao
- Department of Anesthesiology, Fangcheng General Hospital, Nanyang, Henan, P.R. China
| | - Jian-Feng Zhang
- Department of Anesthesiology, The Affiliated Hospital of Hubei University of Arts and Science of Xiangyang Central Hospital, Xiangyang, Hubei, P.R. China
| | - Wu-Hua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, P.R. China
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Monette DL, Brown CA, Benoit JL, McMullan JT, Carleton SC, Steuerwald MT, Eyre A, Pallin DJ. The Impact of Video Laryngoscopy on the Clinical Learning Environment of Emergency Medicine Residents: A Report of 14,313 Intubations. AEM EDUCATION AND TRAINING 2019; 3:156-162. [PMID: 31008427 PMCID: PMC6457358 DOI: 10.1002/aet2.10316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/05/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND The introduction of video laryngoscopy (VL) may impact emergency medicine (EM) residents' intubation practices. METHODS We analyzed 14,313 intubations from 11 EM training sites, July 1, 2002, to December 31, 2012, assessing the likelihood of first-attempt success and likelihood of having a second attempt, by rank and device. We determined whether direct laryngoscopy (DL) first-attempt success decreased as VL became more prevalent using a logistic regression model with proportion of encounters initiated with VL at that center in the prior 90 and 365 days as predictors of DL first-attempt success. RESULTS First-attempt success by PGY-1s was 71% (95% confidence interval [CI] = 63% to 78%); PGY-2s, 82% (95% CI = 78% to 86%); and PGY-3+, 89% (95% CI = 85% to 92%). Residents' first-attempt success rate was higher with the C-MAC video laryngoscope (C-MAC) versus DL, 92% versus 84% (risk difference [RD] = 8%, 95% CI = 4% to 11%), but there was no statistical difference between the GlideScope video laryngoscope (GVL) and DL, 80% versus 84% (RD = -4%, 95% CI = -10% to 1%). PGY-1s were more likely to have a second intubation attempt after first-attempt failure with VL versus DL: 32% versus 18% (RD = 14%, 95% CI = 5% to 23%). DL first-attempt success rates did not decrease as VL became more prevalent. CONCLUSIONS First-attempt success increases with training. Interns are more likely to have a second attempt when using VL. The C-MAC may be associated with increased first-attempt success for EM residents compared with DL or GVL. The increasing prevalence of VL is not accompanied by a decrease in DL success.
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Affiliation(s)
- Derek L. Monette
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Departments of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMA
| | - Calvin A. Brown
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Justin L. Benoit
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOH
| | - Jason T. McMullan
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOH
| | | | | | - Andrew Eyre
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Daniel J. Pallin
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
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Ono Y, Tanigawa K, Shinohara K, Yano T, Sorimachi K, Inokuchi R, Shimada J. Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study. Int J Emerg Med 2017; 10:28. [PMID: 28905252 PMCID: PMC5597568 DOI: 10.1186/s12245-017-0155-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 09/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although human and equipment resources, proper training, and the verification of endotracheal intubation are vital elements of difficult airway management (DAM), their availability in Japanese emergency departments (EDs) has not been determined. How ED type and patient volume affect DAM preparation is also unclear. We conducted the present survey to address this knowledge gaps. METHODS This nationwide cross-sectional study was conducted from April to September 2016. All EDs received a mailed questionnaire regarding their DAM resources, airway training methods, and capnometry use for tube placement. Outcome measures were the availability of: (1) 24-h in-house back-up; (2) key DAM resources, including a supraglottic airway device (SGA), a dedicated DAM cart, surgical airway devices, and neuromuscular blocking agents; (3) anesthesiology rotation as part of an airway training program; and (4) the routine use of capnometry to verify tube placement. EDs were classified as academic, tertiary, high-volume (upper quartile of annual ambulance visits), and urban. RESULTS Of the 530 EDs, 324 (61.1%) returned completed questionnaires. The availability of in-house back-up coverage, surgical airway devices, and neuromuscular blocking agents was 69.4, 95.7, and 68.5%, respectively. SGAs and dedicated DAM carts were present in 51.5 and 49.7% of the EDs. The rates of routine capnometry use (47.8%) and the availability of an anesthesiology rotation (38.6%) were low. The availability of 24-h back-up coverage was significantly higher in academic EDs and tertiary EDs in both the crude and adjusted analysis. Similarly, neuromuscular blocking agents were more likely to be present in academic EDs, high-volume EDs, and tertiary EDs; and the rate of routine use of capnometry was significantly higher in tertiary EDs in both the crude and adjusted analysis. CONCLUSIONS In Japanese EDs, the rates of both the availability of SGAs and DAM carts and the use of routine capnometry to confirm tube placement were approximately 50%. These data demonstrate the lack of standard operating procedures for rescue ventilation and post-intubation care. Academic, tertiary, and high-volume EDs were likely to be well prepared for DAM.
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Affiliation(s)
- Yuko Ono
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, Fukushima, 960-1295, Japan. .,Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan.
| | - Koichi Tanigawa
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, Fukushima, 960-1295, Japan.,Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Tetsuhiro Yano
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, Fukushima, 960-1295, Japan
| | - Kotaro Sorimachi
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, Fukushima, 960-1295, Japan
| | - Ryota Inokuchi
- Department of General and Emergency Medicine, JR Tokyo General Hospital, Tokyo, Japan
| | - Jiro Shimada
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, Fukushima, 960-1295, Japan
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