A survey of nasotracheal intubating skills among Advanced Trauma Life Support course graduates

Nasotracheal intubation for head and neck surgery

Nasotracheal intubation offers the head and neck surgeon more scope for surgical manoeuvre in operations of the mouth, pharynx, larynx and also the neck. Concern over the complications of using this route of intubation and lack of training may be limiting its use. A thorough knowledge of the anatomy, benefits of using nasal vasoconstrictors and attention to technique are prerequisites to maintaining the skill. This article reviews each of these topics and aims to encourage the appropriate use of nasotracheal intubation in current practice.

Cervical spine injury and airway management

Cervical spine injuries occur in 2-5% of blunt trauma patients, and 1-5% of these injuries are initially missed. Data from the large National Emergency X-Radiography Utilisation Study have helped to define the problem in some detail. There is a consensus on how to clear the cervical spine in patients who are alert, but in patients with altered mental status the choice of strategy for spinal clearance is more controversial. Despite obtaining extensive radiological studies, some clinicians will not clear the patient's cervical spine until full recovery of consciousness. As long as manual in-line neck stabilization is applied, rapid sequence induction of anaesthesia, followed by direct laryngoscopy and oral intubation appears to be safe in the patient with a cervical spine injury. If intubation is not urgent, an awake fibreoptic technique is a useful option. If intubation of the patient with a potential cervical spine injury fails, or appropriate experienced personnel are unavailable, the laryngeal mask airway or one of its various modifications are useful alternatives.

Surgical procedure skills of graduating medical students: effects of sex, working, and research experience

BACKGROUND

Surgical procedures constitute an important part of every physician's daily practice. However, few studies have investigated the surgical skills of graduating medical students and, especially, factors that might be related to their degree of surgical competence. The present study sought to gather information on the basic surgical skills of graduating medical students and to establish whether factors influencing the students' competence could be identified and used to improve the teaching of basic surgical skills at medical schools.

METHODS

A questionnaire was sent to all final-year medical students in Finland in 1997. It was returned by 404 (participation rate 80.2%) students. The questionnaire included questions on the theoretical knowledge and successful performance of 10 basic surgical procedures: abdominal paracentesis, application of Sengstake-Blakemoore tube, rubber-band ligation of hemorrhoids, reposition and casting of Colles' fracture, knee arthrocentesis, application of tibial traction, evacuation of subcutaneous abscess, male bladder catheterization, suprapubic catheterization, and nevus excision.

RESULTS

Over 90% of the final-year medical students knew the theory of performing reposition and casting of Colles' fracture, knee arthrocentesis, urinary tract catheterization, and nevus excision, but only 32% (124/393) knew the theory of applying the Sengstake-Blakemoore tube. Nevus excision had been successfully performed by over 90% of the students. Of the emergency or duty procedures, application of the Sengstake-Blakemoore tube and abdominal paracentesis had been successfully performed by 1% (4/393) and 8% (32/393) of the students, respectively, whereas Colles' fracture reposition and suprapubic catheterization had been successfully performed by 46% of the students (182/393 and 179/393, respectively). The age-adjusted odds ratios for performing Colles' fracture reposition (OR 1.59; 95% CI 1.01 to 2.50), application of tibial traction (2.00; 1.03 to 3.89), evacuation of subcutaneous abscess (2.13; 1.25 to 3.62), and suprapubic catheterization (2.23; 1.21 to 4.09) were significantly higher among males than females. Students with working experience had higher odds ratios for performing suprapubic catheterization (OR 6.75; 95% CI 1.99 to 22.84), nevus excision (5.69; 2.49 to 13.0), reposition and casting of Colles' fracture (1.72; 1.01 to 2.94), knee arthrocentesis (4.78; 2.67 to 8.53), and evacuation of subcutaneous abscess (12.9; 6.12 to 27.1) than students without such experience. Students who had done extracurricular research had significantly lower odds ratios for performing evacuation of subcutaneous abscess (0.58; 0.34 to 0.99) than students without such experience. When the five medical faculties in Finland were compared, the highest odds ratios for performing procedures were at the university in which a student logbook was systematically used.

CONCLUSIONS

Final-year medical students have fairly good theoretical knowledge of basic surgical procedures, but the successful performance rates of these procedures range from 1 to 90%. Males have performed surgical procedures significantly more often than females. Working experience clearly enhanced the surgical skills of medical students. However, research experience may impair the learning of these procedures. The systematic use of logbooks seems to be useful.

Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study

STUDY OBJECTIVE

To determine the clinical characteristics of endotracheal intubation in the French emergency prehospital medical system and compare these data with those of other systems.

METHODS

This study was performed in lle de France (Paris Region) in mobile ICUs staffed by physicians. This prospective, descriptive study involved completion of a questionnaire by the operator just after endotracheal intubation was performed.

RESULTS

Six hundred eighty-five (99.1%) of 691 consecutive prehospital intubations were performed successfully in the field. The orotracheal route was used in 96.0%, and no surgical approaches such as cricothyroidotomy were used. Mechanical complications occurred in 84 patients, at a rate of 15.9% for nonarrest patients and 8.1% for arrest patients. A wide variety of sedation protocols were used. Difficult intubations (10.8%) were comparable in incidence to the number seen in US emergency departments, not US prehospital systems. By the same token, intubation success rates (99.1%) were comparable to US EDs and much higher than US prehospital results.

CONCLUSION

The characteristics of French prehospital airway management differ significantly from those of other countries. These differences may be explained by differences in approach to prehospital management rather than differences of skill.

[Rapid sequence anesthetic induction via prehospital tracheal intubation]

The choice of sedation for emergency intubation remains controversial. This lack of consensus has led to various sedation protocols used in French prehospital care setting. A review of data from the literature suggests that the association etomidate-suxamethonium is probable the best choice for rapid sequence intubations in the prehospital setting. Its benefits include protection against myocardial and cerebral ischaemia, decreased risk of pulmonary aspiration, and a stable haemodynamic profile. Randomized studies are needed to substantiate the advantages of the association etomidate-suxamethonium for rapid sequences intubation in the prehospital setting.

Nasotracheal intubation in patients with immobilized cervical spine: a comparison of tracheal tube cuff inflation and fiberoptic bronchoscopy

Tracheal intubation may pose problems in patients with cervical spine injury (CSI). In patients without CSI, the success rate of blind nasotracheal intubation is increased by endotracheal tube (ETT) cuff inflation in the pharynx. The purpose of this study was to assess the efficacy of ETT cuff inflation in the pharynx as an aid to blind nasotracheal intubation in patients with an immobilized cervical spine. The technique was compared with fiberoptic bronchoscopy. Twenty ASA physical status I and II patients undergoing elective surgery in which the trachea was to be intubated nasally were enrolled in this prospective, randomized study. The cervical spine of each patient was immobilized. The trachea of each patient was intubated twice, once using fiberoptic bronchoscopy and once blindly using the technique of ETT cuff inflation in the pharynx. A maximum of three attempts was allowed for intubation using ETT cuff inflation. A maximum of 3 min was allowed for intubation using fiberoptic bronchoscopy. When ETT cuff inflation was used, intubation was successful in 19 of 20 patients (95%); the first attempt at intubation was successful in 14 of 20 patients (70%). Intubation was successful in 19 of 20 patients (95%) when using fiberoptic bronchoscopy. Mean times to intubate were 20.8 +/- 23 s when the ETT cuff was inflated in the pharynx and 60.1 +/- 56 s when using fiberoptic laryngoscopy (P < 0.01). We conclude that both ETT cuff inflation in the pharynx and fiberoptic bronchoscopy are valuable for nasotracheal intubation in patients with an immobilized cervical spine and that ETT cuff inflation can be used as an alternative to fiberoptic bronchoscopy in patients with CSI.

IMPLICATIONS

We compared the technique of endotracheal tube cuff inflation in the pharynx for blind nasotracheal intubation in patients with an immobilized cervical spine with fiberoptic bronchoscopy. There was no significant difference between the success rates of the techniques.