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April MD, Schauer SG, Nikolla DA, Casey JD, Semler MW, Ginde AA, Carlson JN, Long BJ, Brown CA. Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study. Am J Emerg Med 2024; 85:202-207. [PMID: 39288499 DOI: 10.1016/j.ajem.2024.09.014] [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: 06/16/2024] [Revised: 09/01/2024] [Accepted: 09/04/2024] [Indexed: 09/19/2024] Open
Abstract
OBJECTIVE Peri-intubation complications are important sequelae of airway management in the emergency department (ED). Our objective was to quantify the increased risk of complications with multiple attempts at emergency airway intubation in the ED. METHODS This is a secondary analysis of a prospectively collected multicenter registry (National Emergency Airway Registry) consisting of attempted ED intubations among subjects aged >14 years. The primary exposure variable was the number of intubation attempts. The primary outcome measure was the occurrence of peri-intubation major complications within 15 min of intubation including hypotension, hypoxemia, vomiting, dysrhythmias, cardiac arrest, esophageal intubation, and failed airway with cricothyrotomy. We constructed multivariable logistic regression models to determine the associations between complications and the number of intubation attempts while controlling for measured pre-exposure variables. RESULTS There were 19,071 intubations in the NEAR database, of which 15,079 met inclusion for this analysis. Of these, 13,459 were successfully intubated on the first attempt, 1,268 on the second attempt, 269 on the third attempt, 61 on the fourth attempt, and 22 on the fifth or more attempt. A complication occurred in 2,137 encounters (14 %). Major complications accompanied 1,968 encounters (13 %) whereas minor complications affected 315 encounters (2 %). The most common major complication was hypoxia. In our multivariable logistic regression model, odds ratios with 95 % confidence intervals for the occurrence of major complications for multiple attempts compared to first-pass success were 4.4 (3.6-5.3), 7.4 (5.0-10.7), 13.9 (5.6-34.3), and 9.3 (2.1-41.7) for attempts 2-5+ (reference attempt 1), respectively. CONCLUSIONS We found an independent association between the number of intubation attempts among ED patients undergoing emergency airway intubation and the risk of complications.
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Affiliation(s)
- Michael D April
- 14th Field Hospital, Fort Stewart, GA, Georgia; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
| | - Steven G Schauer
- University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Dhimitri A Nikolla
- Department of Emergency Medicine, Allegheny Health Network, Erie, PA, United States of America
| | - Jonathan D Casey
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Matthew W Semler
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Erie, PA, United States of America
| | - Brit J Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America
| | - Calvin A Brown
- Department of Emergency Medicine, Lahey Hospital and Medical Center, Burlington, MA, United States of America
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Long B, Gottlieb M. Emergency medicine updates: Endotracheal intubation. Am J Emerg Med 2024; 85:108-116. [PMID: 39255682 DOI: 10.1016/j.ajem.2024.08.042] [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: 06/17/2024] [Revised: 08/03/2024] [Accepted: 08/24/2024] [Indexed: 09/12/2024] Open
Abstract
INTRODUCTION Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI. OBJECTIVE This paper evaluates key evidence-based updates concerning ETI for the emergency clinician. DISCUSSION ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube. CONCLUSIONS An understanding of literature updates can improve the ED care of patients requiring emergent intubation.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Alsabri M, Abdelwahab OA, Elsnhory AB, Diab RA, Sabesan V, Ayyan M, McClean C, Alhadheri A. Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2024; 13:85. [PMID: 38475918 PMCID: PMC10935931 DOI: 10.1186/s13643-024-02500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting. METHODS We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively. RESULTS Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD = - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD = - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05). CONCLUSION In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.
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Affiliation(s)
- Mohammed Alsabri
- Department of Emergency Medicine, Al-Thawra Modern General Teaching Hospital, Sana'a City, Yemen.
| | | | | | | | | | | | | | - Ayman Alhadheri
- Michigan State University College of Osteopathic Medicine, East Lansing, USA
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Gutierrez GA, Henry J, April MD, Long BJ, Schauer SG. A Market Assessment of Introducer Technology to Aid With Endotracheal Intubation. Mil Med 2024; 189:e54-e57. [PMID: 37279509 DOI: 10.1093/milmed/usad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/14/2023] [Accepted: 05/09/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Endotracheal intubation is a potentially lifesaving procedure. Previously, data demonstrated that intubation remains the most performed airway intervention in the Role 1 setting. Additionally, deployed data demonstrate that casualties intubated in the prehospital setting have worse survival than those intubated in the emergency department setting. Technological solutions may improve intubation success in this setting. Certain intubation practices, including the use of endotracheal tube introducer bougies, facilitate intubation success especially in patients with difficult airways. We sought to determine the current state of the market for introducer devices. MATERIALS AND METHODS This market review utilized Google searches to find products for intubation. The search criteria aimed to identify any device ideal for intubation in the emergency setting. Device data retrieved included manufacturer, device, cost, and design descriptions. RESULTS We identified 12 introducer-variants on the market. Devices varied with regards to composition (latex, silicone, polyethylene, combination of several materials, etc.), tip shape, special features for ease of intubation (markings for depth and visibility, size, etc.), disposability/reuse capability, measurements, and prices. The cost of each device ranged from approximately $5 to $100. CONCLUSIONS We identified 12 introducer-variants on the market. Clinical studies are necessary to determine which devices may improve patient outcomes in the Role 1 setting.
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Affiliation(s)
- Gianna A Gutierrez
- University of the Incarnate Word-School of Medicine, San Antonio, TX 78209, USA
| | - Jevaughn Henry
- University of the Incarnate Word-School of Medicine, San Antonio, TX 78209, USA
| | - Michael D April
- 40th Forward Resuscitative Surgical Detachment, Fort Carson, CO 80902, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brit J Long
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, Levy M, Lindbeck G, Maloney LM, Mattera CJ, Wang CT, Crowe RP, Gage CB, Lang ES, Sholl JM. Evidence-Based Guideline for Prehospital Airway Management. PREHOSP EMERG CARE 2023; 28:545-557. [PMID: 38133523 DOI: 10.1080/10903127.2023.2281363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/05/2023] [Indexed: 12/23/2023]
Abstract
Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.
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Affiliation(s)
- Jeffrey L Jarvis
- Office of the Medical Director, Metropolitan Area EMS Authority, Fort Worth, Texas
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - John W Lyng
- Emergency Medicine, North Memorial Health Hospital Level 1 trauma center, Minneapolis, Minnesota
| | - Nichole Bosson
- EMS, Los Angeles County Department of Health Services, Los Angeles, California
| | | | - Darren A Braude
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Lorin R Browne
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Arinder
- EMS, Global Medical Response Inc., Greenwood Village, Colorado
| | - Scott Bolleter
- EMS, Healthcare Innovation & Sciences Centre, Spring Branch, Texas
| | - Toni Gross
- Department of Emergency Medicine, LCMC Health, New Orleans, Louisiana
| | | | - George Lindbeck
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Lauren M Maloney
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | | | - Cheng-Teng Wang
- Department of Emergency Medicine, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | - Christopher B Gage
- Research, National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Alberta Health Services, Edmonton, Canada
| | - J Matthew Sholl
- National Registry of Emergency Medical Technicians, Columbus, Ohio
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Ismath M, Black H, Hrymak C, Rosychuk RJ, Archambault P, Fok PT, Audet T, Dufault B, Hohl C, Leeies M. Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites. BMC Emerg Med 2023; 23:139. [PMID: 38001415 PMCID: PMC10675858 DOI: 10.1186/s12873-023-00911-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE The risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made. METHODS We conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey ( www.surveymonkey.com ) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models. RESULTS Invitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00). CONCLUSIONS This study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.
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Affiliation(s)
- Muzeen Ismath
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Holly Black
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Carmen Hrymak
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Department of Anesthesiology and Intensive Care, Université Laval, Québec, QC, Canada
| | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Thomas Audet
- Department of Internal Medicine, Université Laval, Québec, QC, Canada
| | - Brenden Dufault
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Corinne Hohl
- Deparment of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.
- Rady Faculty of Health Sciences, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.
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Teixeira MT, Radosevich MA, Wanta BT, Wittwer ED. Video Versus Direct Laryngoscopy for Tracheal Intubation of Adults Who Are Critically Ill: What Does the DEVICE Trial Mean for Anesthesiologists? J Cardiothorac Vasc Anesth 2023; 37:2184-2187. [PMID: 37586952 DOI: 10.1053/j.jvca.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Miguel T Teixeira
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Misty A Radosevich
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Brendan T Wanta
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Erica D Wittwer
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Rochester, MN.
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April MD, Driver B, Schauer SG, Carlson JN, Bridwell RE, Long B, Stang J, Farah S, De Lorenzo RA, Brown CA. Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study. Am J Emerg Med 2023; 72:95-100. [PMID: 37506583 DOI: 10.1016/j.ajem.2023.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/24/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.
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Affiliation(s)
- Michael D April
- 14th Field Hospital, Fort Stewart, GA, United States of America; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
| | - Brian Driver
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; US Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX, United States of America
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, United States of America
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, United States of America
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America
| | - Jamie Stang
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
| | - Subrina Farah
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Robert A De Lorenzo
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States of America
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
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Pass M, Di Rollo N, McNarry AF. Videolaryngoscopy in critical care and emergency locations: moving from debating benefit to implementation. Br J Anaesth 2023; 131:434-438. [PMID: 37507261 DOI: 10.1016/j.bja.2023.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
The recently published INTUBE study subanalysis and DEVICE trial findings both demonstrate a clear benefit of videolaryngoscopy over direct laryngoscopy in facilitating tracheal intubation of patients in the emergency department and ICU. We consider the increasing evidence supporting the use of videolaryngoscopy, the possible reasons behind its relatively slow adoption into clinical practice, and the potential role of the hyperangulated videolaryngoscope blade. We discuss the significance of improved first-pass tracheal intubation success in reducing the overall risk of complications in critically ill patients. Additionally, we address the need for specific training in videolaryngoscopy in order to maximise patient benefit, and propose that adequate training and rehearsal opportunities in videolaryngoscopy can only be realised by widespread and regular use wherever the clinical setting.
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Affiliation(s)
- Marc Pass
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Nicola Di Rollo
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Alistair F McNarry
- Departments of Anaesthesia Western General and St John's Hospitals, NHS Lothian, Edinburgh, UK.
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Kibblewhite C, Todd VF, Howie G, Sanders J, Ellis C, Dittmer B, Garcia E, Swain A, Smith T, Dicker B. Out-of-Hospital emergency airway management practices: A nationwide observational study from Aotearoa New Zealand. Resusc Plus 2023; 15:100432. [PMID: 37547539 PMCID: PMC10400901 DOI: 10.1016/j.resplu.2023.100432] [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: 05/23/2023] [Revised: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Background and Objectives Airway management is crucial for emergency care in critically ill patients outside the hospital setting. An Airway Registry is useful in providing essential information for quality improvement purposes. Therefore, this study aimed to develop an out-of-hospital airway registry and describe airway management practices in Aotearoa New Zealand (AoNZ). Methods Data from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database were used in a retrospective cohort study covering July 2020 to June 2021. All patients receiving airway interventions were included. An airway intervention was defined as one or more of the following: non-drug assisted endotracheal intubation (NDA-ETI), drug-assisted endotracheal intubation (DA-ETI; where a combination of paralytic agent and sedative were used to aid in intubation), laryngeal mask airway (LMA), oropharyngeal airway (OPA), nasopharyngeal airway (NPA), surgical airway (cricothyroidotomy), suction, jaw thrust. Descriptive statistics were analysed using Chi-Square and logistic regression modelling investigated the relationship between advanced airway success and patient characteristics. Results The study included 4,529 patients who underwent 7,779 airway interventions. Basic airway interventions were used most frequently: OPA (45.1%), NPA (29.3%), LMA (28.9%), suction (19.9%) and jaw thrust (17.6%). Advanced airway interventions were used less frequently: NDA-ETI (19.8%), DA-ETI (8.7%), and surgical airways (0.2%). The success rate for ETI (including both NDA-ETI and DA-ETI) was 89.4%, with NDA-ETI success at 85.8% and DA-ETI success at 97.7%. ETI first-pass success rates were significantly lower for males (aOR 0.65, 95%CI 0.48-0.87, p < 0.001) and higher for non-cardiac arrest injury patients (aOR 2.94, 95%CI 1.43-6.00, p < 0.001). In this cohort receiving airway interventions the 1-day mortality rate was 41.1%, demonstrating that a high proportion of these patients were severely clinically compromised. Conclusions Out-of-hospital airway management practices and success rates in AoNZ are comparable to those elsewhere. This research has determined the variables to be used as the AoNZ Paramedic Airway Registry ongoing and has demonstrated baseline outcomes in airway management for ongoing quality improvement using this registry.
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Affiliation(s)
- Chris Kibblewhite
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Verity F. Todd
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Graham Howie
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Josh Sanders
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Craig Ellis
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Bryan Dittmer
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Elena Garcia
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Andy Swain
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
- Wellington Free Ambulance, Wellington, New Zealand
| | - Tony Smith
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Bridget Dicker
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
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12
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Giuliano J, Krishna A, Napolitano N, Panisello J, Shenoi A, Sanders RC, Rehder K, Al-Subu A, Brown C, Edwards L, Wright L, Pinto M, Harwayne-Gidansky I, Parsons S, Romer A, Laverriere E, Shults J, Yamada NK, Walsh CM, Nadkarni V, Nishisaki A. Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU. Crit Care Med 2023; 51:936-947. [PMID: 37058348 DOI: 10.1097/ccm.0000000000005847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN Prospective multicenter interventional quality improvement study. SETTING Ten PICUs in North America. PATIENTS Patients undergoing tracheal intubation in the PICU. INTERVENTIONS VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.
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Affiliation(s)
- John Giuliano
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Ashwin Krishna
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, UW Health American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Calvin Brown
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Lisa Wright
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Matthew Pinto
- Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ilana Harwayne-Gidansky
- Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Medical Center, Albany, NY
| | - Simon Parsons
- Division of Critical Care, Alberta Children's Hospital, Calgary, AB, Canada
| | - Amy Romer
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Laverriere
- Division of Critical Care Medicine and Division of General Anesthesiology at Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicole K Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, ON, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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13
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Venner C. Is it time for mandatory airway assessments for emergency medicine trainees? Emerg Med Australas 2023; 35:521-522. [PMID: 37005065 DOI: 10.1111/1742-6723.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Caroline Venner
- Gladstone Hospital, Gladstone, Queensland, Australia
- Children's Health Queensland Retrieval Service, Brisbane, Queensland, Australia
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14
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Turner JS, Hunter BR, Haseltine ID, Motzkus CA, DeLuna HM, Cooper DD, Ellender TJ, Sarmiento EJ, Menard LM, Kirschner JM. Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis. Emerg Med J 2023; 40:293-299. [PMID: 35393346 DOI: 10.1136/emermed-2021-211968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. METHODS A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. CONCLUSIONS This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.
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Affiliation(s)
- Joseph S Turner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ian D Haseltine
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christine A Motzkus
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hannah M DeLuna
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elisa J Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura M Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan M Kirschner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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15
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Meulendyks S, Korpal D, Jin HJ, Mal S, Pace J. Airway registries in primarily adult, emergent endotracheal intubation: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:11. [PMID: 36890554 PMCID: PMC9993388 DOI: 10.1186/s13049-023-01075-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized. METHODS A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review. RESULTS Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period. CONCLUSIONS Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.
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Affiliation(s)
- Sarah Meulendyks
- Schulich School of Medicine and Dentistry, 1151 Richmond St, London, ON, N6A 5C1, Canada.
| | - Daniel Korpal
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Helen Jingshu Jin
- Schulich School of Medicine and Dentistry, 1151 Richmond St, London, ON, N6A 5C1, Canada
| | - Sameer Mal
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Jacob Pace
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
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York S, Yates A, Frisch A. Emergeny Medicine Resident Trauma Intubation Success and Prior Intubation Experience. J Emerg Med 2023; 64:230-235. [PMID: 36806433 DOI: 10.1016/j.jemermed.2022.12.006] [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: 05/16/2022] [Revised: 08/09/2022] [Accepted: 12/13/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Emergency medicine residents are often involved in the management of trauma airways. There are few data on the correlation between prior intubation experience and first-pass trauma intubation success for emergency medicine residents. OBJECTIVES We attempted to elucidate a relationship between prior resident intubation experience and first-pass success for trauma patient intubation. METHODS We combined two data sets to assess for correlation between prior intubation experience for postgraduate year 2 and 3 residents and first-pass success for trauma patient intubation. Prior intubation experience was gathered from resident procedure logs and trauma intubation data were collected as part of a quality-monitoring program. A univariable logistic regression analysis for all available variables was performed, with first-pass intubation success as the outcome of interest. RESULTS We included 295 consecutive trauma patients intubated at a Level I trauma center where we could link the resident prior intubation experience (total intubations) with intubation attempt quality data. First-pass success for all emergency medicine residents was 82.3% (233/283). Overall successful intubation rate for emergency medicine residents was 90.4% (256/283). The combination of airway management by both the resident and emergency medicine attending provided an overall success rate of 97.3% (287/295). There was no statistically significant association between first-pass success and prior resident intubation experience or any of the other measured variables. CONCLUSION We did not demonstrate any significant correlation between first-pass intubation success and number of prior intubations performed by the emergency medicine resident.
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Affiliation(s)
- Samuel York
- Emergency Medicine Residency Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam Yates
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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17
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Black H, Hall T, Hrymak C, Funk D, Siddiqui F, Sokal J, Satoudian J, Foster K, Kowalski S, Dufault B, Leeies M. A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic. CAN J EMERG MED 2023; 25:123-133. [PMID: 36542309 PMCID: PMC9768405 DOI: 10.1007/s43678-022-00422-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes? METHODS A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days. RESULTS Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172). CONCLUSION A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.
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Affiliation(s)
- Holly Black
- Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Thomas Hall
- Department of Anaesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Carmen Hrymak
- Department of Emergency Medicine, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Duane Funk
- Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Faisal Siddiqui
- Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - John Sokal
- Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jaime Satoudian
- Department of Respiratory Therapy, Health Sciences Center, Winnipeg, MB, Canada
| | - Kendra Foster
- Department of Respiratory Therapy, Health Sciences Center, Winnipeg, MB, Canada
| | - Stephen Kowalski
- Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brenden Dufault
- George & Fay Yee Center for Healthcare Innovation, Winnipeg, MB, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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18
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Variability in Pediatric Emergency Airway Management Laryngoscopy Modality: Clinical Equipoise or Unwarranted Clinical Variation? Ann Emerg Med 2023; 81:123-125. [PMID: 36336543 DOI: 10.1016/j.annemergmed.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
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19
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Garcia SI, Sandefur BJ, Campbell RL, Driver BE, April MD, Carlson JN, Walls RM, Brown CA. First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study. Ann Emerg Med 2023; 81:649-657. [PMID: 36669924 DOI: 10.1016/j.annemergmed.2022.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/08/2022] [Accepted: 10/17/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE We compare intubation first-attempt success with the direct laryngoscope, hyperangulated video laryngoscope, and standard geometry video laryngoscope among emergency medicine residents at various postgraduate years (PGY) of training. METHODS We analyzed prospective data from emergency department (ED) patients enrolled in the National Emergency Airway Registry from January 1, 2016 to December 31, 2018 using mixed-effects logistic regression to assess the association between PGY of training and first-attempt success by the device. RESULTS Among 15,204 intubations performed by emergency medicine trainees, first-attempt success for PGY-1, PGY-2, and PGY3+ residents, respectively were: 78.8% (95% CI, 75.0 to 82.2%), 81.3% (79.4 to 83.0), and 83.6% (95% CI, 82.1 to 85.1) for direct laryngoscope; 87.2% (95% CI, 84.2 to 89.7), 90.4% (95% CI, 88.8 to 91.9%), and 91.2% (95% CI, 89.8 to 92.5%) for hyperangulated video laryngoscope; and 88.7% (95% CI, 86.1 to 90.9), 90.2% (95% CI, 88.7 to 91.5%), and 94.6% (95% CI 93.9 to 95.3%) for standard geometry video laryngoscope. Direct laryngoscope first-attempt success improved for PGY-2 (adjusted odds ratio [aOR],1.41; 95% CI, 1.09 to 1.82) and PGY-3+ (aOR, 1.76; 1.36 to 2.27) trainees compared to PGY-1. Hyperangulated video laryngoscope success also improved for PGY-2 (aOR, 1.51; 1.1 to 2.05) and PGY-3+ (aOR, 1.56; 1.15 to 2.13) trainees compared to PGY-1. For the standard geometry video laryngoscope, only PGY-3+ (aOR, 1.72; 1.25 to 2.36) was associated with improved first-attempt success compared to PGY-1. CONCLUSION Each laryngoscopy device class was associated with improvement in first-attempt success as training progressed. The video laryngoscope outperformed the direct laryngoscope for all operator groups, and PGY-1 trainees achieved higher first-attempt success using a standard geometry video laryngoscope than PGY-3+ trainees using a direct laryngoscope. These findings support the conjecture that in adult patients, a direct laryngoscope should not be routinely used for the first intubation attempt unless clinical circumstances, such as the presence of a soiled airway, would favor its success. These findings need to be validated with prospective randomized clinical trials.
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Affiliation(s)
- Samuel I Garcia
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Benjamin J Sandefur
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Michael D April
- 40th Resuscitative Surgical Detachment, Fort Carson, CO and Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Chrimes N, Higgs A, Hagberg CA, Baker PA, Cooper RM, Greif R, Kovacs G, Law JA, Marshall SD, Myatra SN, O'Sullivan EP, Rosenblatt WH, Ross CH, Sakles JC, Sorbello M, Cook TM. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia 2022; 77:1395-1415. [PMID: 35977431 DOI: 10.1111/anae.15817] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 01/07/2023]
Abstract
Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
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Affiliation(s)
- N Chrimes
- Department of Anaesthesia, Monash Medical Centre, Melbourne, Australia
| | - A Higgs
- Department of Anaesthesia and Intensive Care, Warrington Teaching Hospitals NHS Foundation Trust, Cheshire, UK
| | - C A Hagberg
- Department of Anaesthesiology and Peri-operative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P A Baker
- Department of Anaesthesiology, University of Auckland, New Zealand
- Department of Anaesthesiology, Starship Children's Hospital, Auckland, New Zealand
| | - R M Cooper
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - R Greif
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland
- Department of Medical Education, Sigmund Freud University, Vienna, Austria
| | - G Kovacs
- Departments of Emergency Medicine, Anesthesia, Medical Neurosciences and Division of Medical Education, Dalhousie University, Halifax, Canada
| | - J A Law
- Department of Anesthesia, Pain Management and Peri-operative Medicine, Dalhousie University, Halifax, Canada
| | - S D Marshall
- Department of Critical Care, University of Melbourne, VIC, Australia
- Department of Anaesthesia and Peri-operative Medicine, Monash University, Melbourne, VIC, Australia
| | - S N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - E P O'Sullivan
- Department of Anaesthesiology, St James's Hospital, Dublin, Ireland
| | - W H Rosenblatt
- Department of Anesthesia, Yale School of Medicine, New Haven, CT, USA
| | - C H Ross
- Department of Emergency Medicine, Mercy Health, Javon Bea Hospital, Rockton and Riverside Campuses, Rockford, IL, USA
- Department of Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - J C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - M Sorbello
- Anesthesia and Intensive Care, AOU Policlinico San Marco University Hospital, Catania, Italy
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- School of Medicine, University of Bristol, Bristol, UK
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21
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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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22
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Impact of Intubator's Training Level on First-Pass Success of Endotracheal Intubation in Acute Care Settings: A Four-Center Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070960. [PMID: 35883944 PMCID: PMC9322935 DOI: 10.3390/children9070960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
(1) Background: First-pass success (FPS) of endotracheal intubation is more challenging in children than in adults. We aimed to identify factors associated with FPS of intubation in acute care settings. (2) Methods: We analyzed data of children aged <10 years who underwent intubation within ≤24 h of arrival at four Korean emergency departments (2016−2019). Variables were compared according to FPS. A logistic regression was performed to quantify the association of factors with FPS. An experienced intubator was defined as a senior resident or a specialist. (3) Results: Of 280 children, 169 (60.4%) had FPS. The children with FPS were older (median age, 23.0 vs. 11.0 months; p = 0.018), were less frequently in their infancy (36.1% vs. 50.5%; p = 0.017), and were less likely to have respiratory compromise (41.4% vs. 55.0%; p = 0.030). The children with FPS tended to be more often intubated by experienced intubators than those without FPS (87.0% vs. 78.4%; p = 0.057). Desaturation was rarer in those with FPS. Factors associated with FPS were experienced intubators (aOR, 1.93; 95% CI, 1.01−3.67) and children’s age ≥12 months (1.84; 1.13−3.02). (4) Conclusion: FPS of intubation can be facilitated by deploying or developing clinically competent intubators, particularly for infants, in acute care settings.
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23
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Nichols M, Fouche PF, Bendall JC. Video versus direct laryngoscopy by specialist paramedics in New South Wales: Preliminary results from a new airway registry. Emerg Med Australas 2022; 34:984-988. [PMID: 35717028 DOI: 10.1111/1742-6723.14033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/18/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Video laryngoscopy (VL) is increasingly used as an alternative to direct laryngoscopy (DL) to improve airway visualisation and endotracheal intubation (ETI) success. Intensive Care Paramedics in New South Wales Ambulance, Australia started using VL in 2020, and recorded success in a new advanced airway registry. We used this registry to compare VL to DL. METHODS The present study was a retrospective analysis of out-of-hospital data for ETI by specialist paramedics using an airway registry. We calculated overall and first-pass success for VL versus DL, and compared success using a Χ2 test. RESULTS The DL overall success was 61 out of 78 (78.2%) and VL was 233 out of 246 (94.7%); difference of 16.5% (P < 0.001). First-pass for DL was successful for 49 out of 78 (62.8%) and for VL in 195 out of 246 (79.3%); difference of 16.5% (P = 0.003). There were five (1.6%) patients where both VL and DL were used and in all instances, DL was used first. CONCLUSIONS This analysis of a new airway registry used by specialist paramedics in New South Wales shows a substantial increase in overall and first-pass intubation success with the use of VL when compared to DL.
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Affiliation(s)
- Martin Nichols
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Pieter F Fouche
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Jason C Bendall
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
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24
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Wilhelms SB, Wilhelms DB. Airway management procedures in Swedish emergency department patients - a national retrospective study. BMC Emerg Med 2022; 22:67. [PMID: 35448960 PMCID: PMC9026936 DOI: 10.1186/s12873-022-00627-3] [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: 12/20/2021] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
Background With the on-going debate about which specialty should be responsible for intubations in the emergency department in mind, the aim of this study was to describe the prevalence of endotracheal intubation and other airway management procedures in emergency department patients in Sweden. Methods All patients registered in the Swedish Intensive Care Registry with admission date from January 1 2013 until June 7 2018 and reported admission type “from the emergency department” or “emergency department” reported in the SAPS3 scoring were included. All patients missing codes for procedures were excluded. Results A total of 110,072 admissions from an emergency department to an ICU were registered during the study period. Of these, 41,619 admissions (37.8%) were excluded due to lack of codes for medical procedures. The remaining 68,453 admissions (62.2%) were included, and 31,888 emergency airway procedures (within 3 h from admission time to the intensive care unit) were registered. Invasive emergency airway procedures were the most common type of airway procedure (n = 23,446), followed by non-invasive airway procedures (n = 8377) and high-flow nasal cannula (n = 880). In 2017 a total of 4720 invasive emergency airway management procedures were registered. Conclusions The frequency of invasive airway management procedures in Swedish EDs is low. With approximately 1.9 million adult ED visits per year, this gives an estimated incidence of 2.4 invasive airway management procedures per thousand ED visits in 2017. Trial registration Not applicable.
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Affiliation(s)
- Susanne B Wilhelms
- Department of Anaesthesia and Intensive Care in Linköping, Linköping, Sweden. .,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Department of Clinical Physiology in Linköping, Linköping, Sweden. .,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Daniel B Wilhelms
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Emergency Medicine in Linköping, Linköping, Sweden
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25
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Kübler S, Kiefer N, Ciolka R, Rixecker R, Amarasekara M, Ellerkmann RK. [Tracheal rupture following endotracheal intubation for an emergency cesarean]. Anaesthesist 2022; 71:626-630. [PMID: 35420328 DOI: 10.1007/s00101-022-01116-9] [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: 12/21/2021] [Revised: 02/26/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
This is a case report of a 45-year-old patient, 39 weeks of gestation, who was intubated via rapid sequence induction (RSI) for an emergency cesarean. The indication for emergency cesarean was a pathological cardiotocography during the ejection phase following labor induction.Despite the primary use of a video laryngoscope, there was difficulty aligning the laryngeal axis. Therefore, an internal stylet was used to heavily angulate the endotracheal tube (ETT) to a hockey stick shape to enter the larynx.Postoperative dyspnea and extensive facial swelling were initially diagnosed as an allergic reaction. Only 22 h later the diagnosis of tracheal rupture was confirmed following computer tomography.We hypothesized that the mechanism of injury was due to excessive pressure transmitted to the tip of the ETT. This probably occurred due to a leverage effect caused by the withdrawal of the heavily bent stylet from the ETT, forcing an intratracheal cranial movement of the ETT.By conducting an experiment on a pig's trachea, we were able to visualize this mechanism of injury. In addition, we were able to demonstrate that bending the stylet to a similar angle as the laryngoscope blade led to minimal movement of the tip of the ETT.Therefore, when using a stylet during intubation, we recommend bending the ETT and stylet to the shape of the used laryngoscope blade and retracting the stylet at a similar angle to avoid complications, such as tracheal rupture.
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Affiliation(s)
- S Kübler
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Klinikum Dortmund gGmbH, Beurhausstr. 40, 44137, Dortmund, Deutschland.
| | - N Kiefer
- Klinik für Anästhesiologie und Operative Intensivmedizin, Marien Hospital Düsseldorf, Düsseldorf, Deutschland
| | - R Ciolka
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Klinikum Dortmund gGmbH, Beurhausstr. 40, 44137, Dortmund, Deutschland
| | - R Rixecker
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Klinikum Dortmund gGmbH, Beurhausstr. 40, 44137, Dortmund, Deutschland
| | - M Amarasekara
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Klinikum Dortmund gGmbH, Beurhausstr. 40, 44137, Dortmund, Deutschland
| | - R K Ellerkmann
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Klinikum Dortmund gGmbH, Beurhausstr. 40, 44137, Dortmund, Deutschland
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26
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To View or Not To View? Standard Geometry Video Laryngoscopes and Screen Visualization. Ann Emerg Med 2022; 79:344-347. [PMID: 35337471 DOI: 10.1016/j.annemergmed.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 12/31/2022]
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27
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Imach S, Kölbel B, Böhmer A, Keipke D, Ahnert T. Re-creating reality: validation of fresh frozen full cadaver airway training with videolaryngoscopy and bougie FIRST strategy. Scand J Trauma Resusc Emerg Med 2022; 30:18. [PMID: 35279197 PMCID: PMC8917638 DOI: 10.1186/s13049-022-01006-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Tracheal intubation is the gold standard in emergency airway management. One way of measuring intubation quality is first pass success rate (FPSR). Mastery of tracheal intubation and maintenance of the skill is challenging for non-anesthesiologists. A combination of individual measures can increase FPSR. Videolaryngoscopy is an important tool augmenting laryngeal visualization. Bougie-first strategy can further improve FPSR in difficult airways. Standardized positioning maneuvers and manipulation of the soft tissues can enhance laryngeal visualization. Fresh frozen cadavers (FFC) are superior models compared to commercially manufactured manikins. By purposefully manipulating FFCs, it is possible to mimic the pre-hospital intubation conditions of helicopter emergency medical service (HEMS). Methods Twenty-four trauma surgeons (12 per Group, NOVICES: no pre-hospital experience, HEMS: HEMS physicians) completed an airway training course using FFCs. The FFCs were modified to match airway characteristics of 60 prospectively documented intubations by HEMS physicians prior to the study (BASELINE). In four scenarios the local HEMS airway standard (1: unaided direct laryngoscopy (DL), OLD) was compared to two scenarios with modifications of the intubation technique (2: augmented DL (bougie and patient positioning), 3: augmented videolaryngoscopy (aVL)) and a control scenario (4: VL and bougie, positioning by participant, CONTROL). FPSR, POGO score, Cormack and Lehane grade and duration of intubation were recorded. No participant had anesthesiological qualifications or experience in VL. Results The comparison between CONTROL and BASELINE revealed a significant increase of FPSR and achieved C&L grade for HEMS group (FPSR 100%, absolute difference 23%, p ≤ .001). The use of videolaryngoscopy, bougie, and the application of positioning techniques required significantly more time in the CONTROL scenario (HEMS group: mean 34.0 s (IQR 28.3–47.5), absolute difference to BASELINE: 13.0 s, p = .045). The groups differed significantly in the median number of real-life intubations performed in any setting (NOVICES n = 5 (IQR 0–18.75), HEMS n = 68 (IQR 37.25–99.75)). In the control scenario no significant differences were found between both groups. The airway characteristics of the FFC showed no significant differences compared to BASELINE. Conclusion Airway characteristics of a pre-hospital patient reference group cared for by HEMS were successfully reproduced in a fresh frozen cadaver model. In this setting, a combination of evidence based airway management techniques results in high FPSR and POGO rates of non-anesthesiological trained users. Comparable results (FPSR, POGO, duration of intubation) were achieved regardless of previous provider experience. The BOAH concept can therefore be used in the early stages of airway training and for skill maintenance.
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28
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [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: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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29
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Counts CR, Benoit JL, McClelland G, DuCanto J, Weekes L, Latimer A, Hagahmed M, Guyette FX. Novel Technologies and Techniques for Prehospital Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:129-136. [PMID: 35001820 DOI: 10.1080/10903127.2021.1992055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Novel technologies and techniques can influence airway management execution as well as procedural and clinical outcomes. While conventional wisdom underscores the need for rigorous scientific data as a foundation before implementation, high-quality supporting evidence is frequently not available for the prehospital setting. Therefore, implementation decisions are often based upon preliminary or evolving data, or pragmatic information from clinical use. When considering novel technologies and techniques. NAEMSP recommends:Prior to implementing a novel technology or technique, a thorough assessment using the best available scientific data should be conducted on the technical details of the novel approach, as well as the potential effects on operations and outcomes.The decision and degree of effort to adopt, implement, and monitor a novel technology or technique in the prehospital setting will vary by the quality of the best available scientific and clinical information:• Routine use - Technologies and techniques with ample observational but limited or no interventional clinical trial data, or with strong supporting in-hospital data. These techniques may be reasonably adopted in the prehospital setting. This includes video laryngoscopy and bougie-assisted intubation. • Limited use - Technologies and techniques with ample pragmatic clinical use information but limited supporting scientific data. These techniques may be considered in the prehospital setting. This includes suction-assisted laryngoscopy and airway decontamination and cognitive aids. • Rare use - Technologies and techniques with minimal clinical use information. Use of these techniques should be limited in the prehospital setting until evidence exists from more stable clinical environments. This includes intubation boxes.The use of novel technologies and techniques must be accompanied by systematic collection and assessment of data for the purposes of quality improvement, including linkages to patient clinical outcomes.EMS leaders should clearly identify the pathways needed to generate high-quality supporting scientific evidence for novel technologies and techniques.
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30
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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31
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Ferreira LCM, Oliveira A, Pereira C, Guedes A, Assunção JP. Scarlet fever in an adult patient: A challenging diagnosis in an airway emergency. SAGE Open Med Case Rep 2021; 9:2050313X211049908. [PMID: 34659770 PMCID: PMC8511905 DOI: 10.1177/2050313x211049908] [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: 04/26/2021] [Accepted: 09/13/2021] [Indexed: 11/22/2022] Open
Abstract
Scarlet fever is essentially a childhood disease, although it may occur in all ages. Early diagnosis and treatment are essential in preventing the spread of infection and progression to life-threatening complications. The case presented describes the clinical difficulty in the diagnosis of scarlet fever in an adult patient with acute involvement of the airway (oedematous laryngitis) and the need for emergent orotracheal intubation and eventually tracheotomy. A high degree of suspicion related to the airway involvement is of utmost importance in an emergency room setting.
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Affiliation(s)
| | - Ana Oliveira
- Hospital Center Tondela-Viseu, Anesthesiology Service,
Viseu, Portugal
| | - Cláudia Pereira
- Hospital Center Tondela-Viseu, Anesthesiology Service,
Viseu, Portugal
| | - Alexandra Guedes
- Hospital Center Tondela-Viseu, Anesthesiology Service,
Viseu, Portugal
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32
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Kei J, Mebust DP. Effects of cardiopulmonary resuscitation on direct versus video laryngoscopy using a mannequin model. Am J Emerg Med 2021; 50:587-591. [PMID: 34563941 DOI: 10.1016/j.ajem.2021.09.031] [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: 07/22/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION During the last decade, guidelines for cardiopulmonary resuscitation has shifted, placing chest compressions and defibrillation first and airway management second. Physicians are being forced to intubate simultaneously with uninterrupted, high quality chest compressions. Using a mannequin model, this study examines the differences between direct and video laryngoscopy, comparing their performance with and without simultaneous chest compressions. METHODS Fifty emergency medicine physicians were randomly assigned to intubate a mannequin six times, using direct laryngoscopy (DL) and with two video laryngoscopy (VL) systems, a C-MAC traditional Macintosh blade and a GlideScope hyperangulated blade, with and without simultaneous chest compressions. A total of 300 intubations were completed and variables including intubation times, accuracy, difficulty, success rates and glottic views were recorded. RESULTS The C-MAC VL system resulted in quicker intubations compared to DL (p = 0.007) and the GlideScope VL system (p = 0.039) during active chest compressions. Compared to DL, intubations were rated easier for both the C-MAC (p < 0.0001) and the GlideScope (p < 0.0001). Intubation failure rates were also higher when DL was used compared to either the C-MAC or GlideScope (p = 0.029). VL devices provided a superior overall Cormack-Lehane grade view compared to DL (p < 0.0001). The presence of chest compressions significantly impaired Cormack-Lehane views during direct laryngoscopy (p = 0.007). Chest compressions made the intubation more difficult under DL (p = 0.002) and when using the C-MAC (p = 0.031). Chest compressions also made ETT placement less accurate when using DL (p = 0.004). CONCLUSION Using a mannequin model, the C-MAC conventional VL blade resulted in decrease intubation times compared with DL or the GlideScope hyperangulated VL blade system. Overall, VL out performed DL in terms of providing a superior glottic view, minimizing failed attempts, and improving physician's overall perception of intubation difficulty. Chest compressions resulted in worse Cormack-Lehane views and higher rates of inaccurate endotracheal tube placement with DL, compared to VL.
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Affiliation(s)
- Jonathan Kei
- Kaiser Permanente Medical Center, Department of Emergency Medicine, 4647 Zion Ave., San Diego, CA 92120, United States of America.
| | - Donald P Mebust
- Kaiser Permanente Medical Center, Department of Emergency Medicine, 4647 Zion Ave., San Diego, CA 92120, United States of America
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Trent SA, Kaji AH, Carlson JN, McCormick T, Haukoos JS, Brown CA. Video Laryngoscopy Is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry. Ann Emerg Med 2021; 78:708-719. [PMID: 34417072 DOI: 10.1016/j.annemergmed.2021.07.115] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/28/2021] [Accepted: 07/12/2021] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVE We sought to (1) characterize emergency department (ED) intubations in trauma patients and estimate (2) first-pass success and (3) the association between patient and intubation characteristics and first-pass success. METHODS We performed a secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). Descriptive statistics were calculated for all patients who were intubated for trauma at 23 NEAR EDs between 2016 and 2018. We evaluated first-pass success in patients intubated by (1) emergency or pediatric emergency physicians, (2) using rapid sequence intubation or no medications, and (3) either direct laryngoscopy or video laryngoscopy. We used propensity score matching with a generalized linear mixed-effects model to estimate the associations between patient and intubation characteristics and first-pass success. RESULTS Of the 19,071 intubations in NEAR, 4,449 (23%) were for trauma, and nearly all (88%) had at least one difficult airway characteristic. Prevalence of first-pass success was 86.8% (95% confidence interval [CI]: 83.3% to 90.3%). Most patients were intubated with video laryngoscopy, and patients were more likely to be intubated on first-pass with video laryngoscopy as compared to direct laryngoscopy (90% versus 79%). After propensity score matching, video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9). Additionally, an initial impression of difficult airway, blood/vomit in the airway, and use of external laryngeal manipulation were all associated with decreased odds of first-pass success. CONCLUSION Emergency physicians are successful at intubating patients in the setting of trauma, and video laryngoscopy is associated with twice the odds of first-pass success when compared to direct laryngoscopy.
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Affiliation(s)
- Stacy A Trent
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA; Department of Emergency Medicine, University of California Los Angeles School of Medicine, Los Angeles, CA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA
| | - Taylor McCormick
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
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Nielsen JR, Lim KS. Management of the Difficult Airway. N Engl J Med 2021; 385:668-669. [PMID: 34379935 DOI: 10.1056/nejmc2109513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- James R Nielsen
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Kar-Soon Lim
- Concord Repatriation General Hospital, Sydney, NSW, Australia
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Levin NM, Fix ML, April MD, Arana AA, Brown CA. The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients. CAN J EMERG MED 2021; 23:518-527. [PMID: 33837951 DOI: 10.1007/s43678-021-00119-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/23/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The recommended rocuronium dose for rapid sequence intubation is 1.0 mg/kg; however, the optimal dose for emergency airway management is not clear. We assessed the relationship between rocuronium dose and first-attempt success among emergency department (ED) patients undergoing rapid sequence intubation. METHODS This is a secondary analysis of the National Emergency Airway Registry (NEAR), an observational 25-center registry of ED intubations. Ninety percent recording compliance was required from each site for data inclusion. We included all patients > 14 years of age who received rocuronium for rapid sequence intubation from 1 Jan 2016 to 31 Dec 2018. We compared first-attempt success between encounters using alternative rocuronium doses (< 1.0, 1.0-1.1, 1.2-1.3 and ≥1.4 mg/kg). We performed logistic regressions to control for predictors of difficult airways, indication, pre-intubation hemodynamics, operator, body habitus and device. We also performed subgroup analyses stratified by device (direct vs. video laryngoscopy). We calculated univariate descriptive statistics and odds ratios (OR) from multivariable logistic regressions with cluster-adjusted 95% confidence intervals (CI). RESULTS 19,071 encounters were recorded during the 3-year period. Of these, 8,034 utilized rocuronium for rapid sequence intubation. Overall, first attempt success was 88.4% for < 1.0 mg/kg, 88.1% for 1.0-1.1 mg/kg, 89.7% for 1.2-1.3 mg/kg, and 92.2% for ≥1.4 mg/kg. Logistic regression demonstrated that when direct laryngoscopy was used and when compared to the standard dosing range of 1.0-1.1 mg/kg, the adjusted odds of a first attempt success was significantly higher in ≥1.4 mg/kg group at 1.9 (95% CI 1.3-2.7) relative to the other dosing ranges, OR 0.9 (95% CI 0.7-1.2) for < 1.0 mg/kg and OR 1.2 (95% CI 0.9-1.7) for the 1.2-1.3 mg/kg group. First-attempt success was similar across all rocuronium doses among patients utilizing video laryngoscopy. Patients who were hypotensive (SBP < 100 mmHg) prior to intubation had higher first-attempt success 94.9% versus 88.6% when higher doses of rocuronium were used. The rates of all peri-intubation adverse events and desaturation were similar between dosing groups, laryngoscope type utilized and varying pre-intubation hemodynamics. CONCLUSIONS Rocuronium dosed ≥1.4 mg/kg was associated with higher first attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension with no increase in adverse events. We recommend further prospective evaluation of the dosing of rocuronium prior to offering definitive clinical guidance.
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Affiliation(s)
- Nicholas M Levin
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
| | - Megan L Fix
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael D April
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Allyson A Arana
- The United Stated Army Institute of Surgical Research, San Antonio, TX, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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36
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Grissom TE, Samet RE. The Anesthesiologist's Role in Teaching Airway Management to Nonanesthesiologists: Who, Where, and How. Adv Anesth 2021; 38:131-156. [PMID: 34106831 PMCID: PMC7534755 DOI: 10.1016/j.aan.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA
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Kaisler MC, Hyde RJ, Sandefur BJ, Kaji AH, Campbell RL, Driver BE, Brown CA. Awake intubations in the emergency department: A report from the National Emergency Airway Registry. Am J Emerg Med 2021; 49:48-51. [PMID: 34062317 DOI: 10.1016/j.ajem.2021.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance. METHODS We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs). RESULTS Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]). CONCLUSION Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.
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Affiliation(s)
- Maria C Kaisler
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN, 55905, United States.
| | - Robert J Hyde
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN, 55905, United States.
| | - Benjamin J Sandefur
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN, 55905, United States.
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center at the David Geffen School of Medicine at UCLA, 924 Westwood Blvd #300, Los Angeles, CA, 99095, United States.
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN, 55905, United States.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 730 S. 8th St, Minneapolis, MN, 55415, United States.
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St. Boston, MA, 02215, United States.
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Affiliation(s)
- Thomas Heidegger
- From the Department of Anesthesia, Spital Grabs, Grabs, and the Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern - both in Switzerland; and the Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
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April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, Brown CA. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation 2021; 162:403-411. [PMID: 33684505 DOI: 10.1016/j.resuscitation.2021.02.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 01/21/2023]
Abstract
AIM To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. METHODS This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. RESULTS Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. CONCLUSIONS Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.
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Affiliation(s)
- Michael D April
- From the 40th Forward Resuscitative Surgical Detachment, 627th Hospital Center, Fort Carson, CO, USA; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Allyson Arana
- United States Army Institute of Surgical Research, San Antonio, TX, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - William T Davis
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Joshua J Oliver
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA, USA
| | - Shane M Summers
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Ryder Trauma Center, Miami, FL, USA
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Abstract
Purpose of Review This paper will evaluate the recent literature and best practices in airway management in critically ill patients. Recent Findings Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations. Summary There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.
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41
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Miller KA, Marchese A, Luff D, Nagler J. Conceptualizing intubation sharing: A descriptive qualitative study of videolaryngoscopy for pediatric emergency airway management. AEM EDUCATION AND TRAINING 2021; 5:e10589. [PMID: 33842814 PMCID: PMC8019533 DOI: 10.1002/aet2.10589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/31/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study characterizes clinical and educational practices around the use of videolaryngoscopy in pediatric emergency airway management through qualitative exploration. METHODS This is a descriptive qualitative study using semi-structured interviews of emergency medicine physicians. Physicians were selected by theoretical sampling from urban, tertiary care pediatric hospitals across the United States until theoretical data saturation was achieved. The study applied a constructivist grounded theory approach to data collection and analysis. Manual line-by-line coding of interview transcripts was used initially, then grouped into categories with constant comparative analysis to generate the final coding scheme organized by themes and subthemes. Finally, memo-writing and iterative analysis meetings explored relationships between themes and identified an interpretive model. RESULTS Theoretical saturation was achieved after 10 of the initial 12 interviews. Emerging from the data were six themes that describe the concept of intubation sharing: (1) Videolaryngoscopy encompasses multiple modalities that all provide a shared view and ability to record; (2) Airway experts and systems help realize the full potential of videolaryngoscopy; (3) Videolaryngoscopy can be a clinical, educational, quality assurance and research tool; (4) Some skills required for videolaryngoscopy are unique, while others overlap with direct laryngoscopy; (5) Videolaryngoscopy allows a coaching laryngoscopist to provide real-time guidance to the primary laryngoscopist from a shared view; (6) Videolaryngoscopy provides an opportunity for post-intubation coaching and feedback and shared learning from a single experience for the provider community. CONCLUSIONS Through this multicenter qualitative interview study, we derived the concept of intubation sharing through videolaryngoscopy for real-time and remote coaching, for both the primary laryngoscopist and the community of emergency medicine providers who intubate.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine at Boston Children's HospitalHarvard Medical SchoolBostonMAUSA
| | - Ashley Marchese
- Division of Emergency Medicine at Boston Children's HospitalHarvard Medical SchoolBostonMAUSA
| | - Donna Luff
- Department of Pediatrics at Boston Children’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Joshua Nagler
- Division of Emergency Medicine at Boston Children's HospitalHarvard Medical SchoolBostonMAUSA
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García-Pintos MF, Erramouspe PJ, Schandera V, Murphy K, McCalla G, Taylor G, Tyler KR, Richards JR, Laurin EG. Comparison of Video Versus Direct Laryngoscopy: A Prospective Prehospital Air Medical Services Study. Air Med J 2021; 40:45-49. [PMID: 33455625 DOI: 10.1016/j.amj.2020.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/19/2020] [Accepted: 10/29/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Videolaryngoscopy (VL) in the prehospital setting remains controversial, with conflicting data on its utility. We compared C-MAC VL (Karl Storz, Tuttlingen, Germany) versus direct laryngoscopy (DL) in the prehospital setting, recording the grade of the glottic view, first pass success (FPS), overall success, and equipment functionality. METHODS We conducted a prospective observational study with a convenience sample of 49 adult patients who were intubated by flight crew nurses and paramedics using the C-MAC videolaryngoscope from April to November 2013. We compared Cormack-Lehane (CL) grades of view for DL and VL, intubation success rates, and equipment functionality. RESULTS CL grades 1 or 2 were obtained with 24 patients (49%) with DL and 45 patients (92%) with VL. Of the 25 patients (51%) who had a CL grade 3 or 4 view on DL, 22 of those patients (88%) converted to a CL grade 1 or 2 with VL (P < .001). There was an overall success rate of 96% and an FPS rate of 71%. The C-MAC videolaryngoscope was functional during intubation 100% of the time. CONCLUSION VL improved glottic visualization compared with DL. The FPS and overall intubation success rates were similar to other published prehospital studies using VL. The C-MAC provided reliable, high-quality video despite demanding prehospital conditions.
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Affiliation(s)
| | - Pablo Joaquin Erramouspe
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA; Faculty of Health, Queensland University of Technology, Translational Research Institute, Brisbane, Queensland, Australia
| | - Verena Schandera
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
| | - Kevin Murphy
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA; Cottage Hospital, Santa Barbara, CA
| | | | - Greg Taylor
- REACH Air Medical Services, Santa Rosa, CA; Seattle Children's Hospital, Seattle, WA
| | - Katren R Tyler
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
| | - John R Richards
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
| | - Erik G Laurin
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
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Norii T, Makino Y, Unuma K, Hatch GM, Adolphi NL, Dallo S, Albright D, Sklar DP, Braude D. Extraglottic Airway Device Misplacement: A Novel Classification System and Findings in Postmortem Computed Tomography. Ann Emerg Med 2021; 77:285-295. [PMID: 33455839 DOI: 10.1016/j.annemergmed.2020.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ. METHODS We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications. RESULTS We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries. CONCLUSION We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements.
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Affiliation(s)
- Tatsuya Norii
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM.
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Gary M Hatch
- Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Natalie L Adolphi
- Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, NM; Center for Forensic Imaging, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Sarah Dallo
- Department of Biochemistry and Molecular Biology, University of New Mexico, Albuquerque, NM
| | - Danielle Albright
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - David P Sklar
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | - Darren Braude
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM; Department of Anesthesiology, University of New Mexico Health Sciences Center, Albuquerque, NM
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44
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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45
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Howson A, Goodliff A, Horner D. BET 2: Video laryngoscopy for patients requiring endotracheal intubation in the emergency department. Emerg Med J 2020; 37:381-383. [PMID: 32487710 DOI: 10.1136/emermed-2020-209962.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A short-cut review of the literature was carried out to examine whether video laryngoscopy (VL) could improve first-pass success and reduce complication rates in ED patients requiring endotracheal intubation, when compared with direct laryngoscopy. Four papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that current evidence suggests VL is likely to improve first-pass success and reduce oesophageal intubation rates, but there is no evidence at present that it improves clinically relevant outcomes. In addition, no difference was found between first-pass success rates in senior/experienced operators, who should use techniques with which they are familiar.
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Affiliation(s)
- Abbie Howson
- Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Alex Goodliff
- Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Daniel Horner
- Emergency and Critical Care Medicine, Salford Royal NHS Foundation Trust, Salford, UK
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46
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Kovacs G, Levitan R. Redirecting the Laryngoscopy Debate and Optimizing Emergency Airway Management. Acad Emerg Med 2020; 27:1366-1369. [PMID: 32506607 DOI: 10.1111/acem.14043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- George Kovacs
- Department of Emergency Medicine Dalhousie University QEII Health Sciences Centre Halifax NS Canada
| | - Richard Levitan
- Dartmouth Geisel School of Medicine Department of Medicine Dartmouth‐Hitchcock Medical Center Lebanon NH USA
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47
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Driver BE, Mosier JM, Brown CA. The Importance of the Intubation Process for the Safety of Emergency Airway Management. Acad Emerg Med 2020; 27:1362-1365. [PMID: 32519410 DOI: 10.1111/acem.14041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Brian E. Driver
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN USA
| | - Jarrod M. Mosier
- Department of Medicine Section of Pulmonary Critical Care, Allergy, and Sleep Tuscon AZ USA
- Department of Emergency Medicine University of Arizona Tucson AZ USA
| | - Calvin A Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Boston MA USA
- Harvard Medical School Boston MA USA
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48
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de Alencar JCG, Marques B, Marchini JFM, Marino LO, Ribeiro SCDC, Bueno CG, da Cunha VP, Lazar Neto F, Valente FS, Rahhal H, Pereira JBR, Padrão EMH, Wanderley APB, Costa MGP, Brandão Neto RA, Souza HP. First-attempt intubation success and complications in patients with COVID-19 undergoing emergency intubation. J Am Coll Emerg Physicians Open 2020; 1:699-705. [PMID: 32838394 PMCID: PMC7436702 DOI: 10.1002/emp2.12219] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 11/08/2022] Open
Abstract
Objectives To evaluate the first-attempt success rates and complications of endotracheal intubation of coronavirus disease 2019 (COVID-19) patients by emergency physicians. Methods This prospective observational study was conducted from March 24, 2020 through May 28, 2020 at the emergency department (ED) of an urban, academic trauma center. We enrolled patients consecutively admitted to the ED with suspected or confirmed COVID-19 submitted to endotracheal intubation. No patients were excluded. The primary outcome was first-attempt intubation success, defined as successful endotracheal tube placement with the first device passed (endotracheal tube) during the first laryngoscope insertion confirmed with capnography. Secondary outcomes included the following complications: hypotension, hypoxemia, aspiration, and esophageal intubation. Results A total of 112 patients with confirmed or suspected COVID-19 were enrolled. Median age was 61 years and 61 patients (54%) were men. The primary outcome, first-attempt intubation success, was achieved in 82% of patients. Among the 20 patients who were not intubated on the first attempt, 75% were intubated on the second attempt and 20% on the third attempt; cricothyrotomy was performed in 1 patient. Forty-eight (42%) patients were hypotensive and required norepinephrine immediately post-intubation. Fifty-eight (52%) experienced peri-intubation hypoxemia, and 2 patients (2%) had cardiac arrest. There were no cases of failed intubation resulting in death up to 24 hours after the procedure. Conclusion Emergency physicians achieve high success rates when intubating COVID19 patients, although complications are frequent. However, these findings should be considered provisional until their generalizability is assessed in their institutions and setting.
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Affiliation(s)
| | - Bruno Marques
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | - Lucas Oliveira Marino
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | - Cauê Gasparotto Bueno
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Victor Paro da Cunha
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Felippe Lazar Neto
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Fernando Salvetti Valente
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Hassan Rahhal
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | | | | | | | | | - Heraldo Possolo Souza
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
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49
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Lower maximum forces on oral structures when using gum-elastic bougie than when using endotracheal tube and stylet during both direct and indirect laryngoscopy by novices: a crossover study using a high-fidelity simulator. BMC Emerg Med 2020; 20:34. [PMID: 32375651 PMCID: PMC7201614 DOI: 10.1186/s12873-020-00328-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Applying excessive force during endotracheal intubation (ETI) is associated with several complications, including dental trauma and hemodynamic alterations. A gum-elastic bougie (GEB), a type of tracheal tube introducer, is a useful airway adjunct for patients with poor laryngoscopic views. However, how the use of a GEB affects the force applied during laryngoscopy is unclear. We compared the force applied on the oral structures during ETI performed by novices using the GEB versus an endotracheal tube + stylet. METHODS This prospective crossover study was conducted from April 2017 to March 2019 in a public medical university in Japan. In total, 209 medical students (4th and 5th grade, mean age of 23.7 ± 2.0 years) without clinical ETI experience were recruited. The participants used either a Macintosh direct laryngoscope (DL) or C-MAC video laryngoscope (VL) in combination with a GEB or stylet to perform ETI on a high-fidelity airway management simulator. The order of the first ETI method was randomized to minimize the learning curve effect. The outcomes of interest were the maximum forces applied on the maxillary incisors and tongue during laryngoscopy. The implanted sensors in the simulator quantified these forces automatically. RESULTS The maximum force applied on the maxillary incisors was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (39.0 ± 23.3 vs. 47.4 ± 32.6 N, P < 0.001) and C-MAC VL (38.9 ± 18.6 vs. 42.0 ± 22.1 N, P < 0.001). Similarly, the force applied on the tongue was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (31.9 ± 20.8 vs. 37.8 ± 22.2 N, P < 0.001) and C-MAC VL (35.2 ± 17.5 vs. 38.4 ± 17.5 N, P < 0.001). CONCLUSIONS Compared with the use of an endotracheal tube + stylet, the use of a GEB was associated with lower maximum forces on the oral structures during both direct and indirect laryngoscopy performed by novices. Our results suggest the expanded role of a GEB beyond an airway adjunct for difficult airways.
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50
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Brown CA, Mosier JM, Carlson JN, Gibbs MA. Pragmatic recommendations for intubating critically ill patients with suspected COVID-19. J Am Coll Emerg Physicians Open 2020; 1:80-84. [PMID: 32427182 PMCID: PMC7228350 DOI: 10.1002/emp2.12063] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Calvin A Brown
- Department of Emergency Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Jarrod M Mosier
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine University of Arizona Tucson Arizona USA.,Department of Emergency Medicine University of Arizona Tucson Arizona USA
| | - Jestin N Carlson
- Department of Emergency Medicine Allegheny Health Network Erie Pennsylvania USA
| | - Michael A Gibbs
- Department of Emergency Medicine Carolinas Medical Center Charlotte North Carolina USA
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