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Tangkulpanich P, Angkoontassaneeyarat C, Trainarongsakul T, Jenpanitpong C. Factors Associated with Postintubation Hypotension Among Patients with Suspected Sepsis in Emergency Department. Open Access Emerg Med 2023; 15:427-436. [PMID: 38022743 PMCID: PMC10656833 DOI: 10.2147/oaem.s426822] [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: 06/20/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Postintubation hypotension (PIH) is a recognized complication that increases both in-hospital mortality and hospital length of stay. Sepsis is reportedly a factor associated with PIH. However, no study to date has examined which factors, including the intubation method, may be clinical predictors of PIH in patients with sepsis. This study aims to investigate factors associated with the occurrence of PIH in patients with suspected sepsis in emergency department. Patients and Methods This retrospective cross-sectional study was performed over a 5-year period (January 2013-December 2017) and involved patients with suspected sepsis who underwent endotracheal intubation in the emergency department of Ramathibodi Hospital. The patients were divided into those with and without PIH, and factors associated with the occurrence of PIH were analyzed. PIH was defined as any recorded systolic blood pressure of <90 mmHg within 60 minutes of intubation. Results In total, 394 patients with suspected sepsis were included. PIH occurred in 106 patients (26.9%) and was associated with increased in-hospital mortality (43.00% in the PIH group vs 31.25% in the non-PIH group, P = 0.034). Multivariable logistic regression showed that the factors associated with PIH were an age of ≥61 years (adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.14-4.43; P = 0.019) and initial serum lactate concentration of >4.4 mmol/L (aOR 2.00; 95% CI 1.16-3.46; P = 0.013). Rapid sequence intubation and difference types of induction agents was unrelated to PIH. Conclusion Monitoring the development of PIH in patients with sepsis is essential because of its correlation with higher in-hospital mortality. This is particularly critical for older individuals and those with severe infections and high initial lactate concentrations.
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Affiliation(s)
- Panvilai Tangkulpanich
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Thavinee Trainarongsakul
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Holtan-Hartwig I, Johnsen LR, Dahl V, Haidl F. Preoperative Gastric Ultrasound in Surgical Patients who Undergo Rapid Sequence Induction Intubation. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chotalia M, Pirrone C, Mangham T, Torlinska B, Mullhi R, England K, Torlinski T. The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study. J Burn Care Res 2020; 41:1290-1296. [PMID: 32504540 DOI: 10.1093/jbcr/iraa092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Christine Pirrone
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Australia
| | - Thomas Mangham
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Barbara Torlinska
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham,, UK
| | - Randeep Mullhi
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Kaye England
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
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Lao WP, Crawley BK. Airway Considerations in Transgender Patients: Complicated Intubation. EAR, NOSE & THROAT JOURNAL 2020; 100:755S-756S. [PMID: 32126818 DOI: 10.1177/0145561320910680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Wilson P Lao
- 12221Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Brianna K Crawley
- Loma Linda Voice and Swallowing Center, Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Trauma and Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
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Mao Y, Qin ZH. Association of apneic oxygenation with decreased desaturation rates during rapid sequence intubation by a Chinese emergency medicine service. Int J Clin Exp Med 2015; 8:11428-11434. [PMID: 26379959 PMCID: PMC4565342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/25/2015] [Indexed: 06/05/2023]
Abstract
Rapid and safe airway management has always been of paramount importance in successful management of critically ill and injured patients in the emergency department. The achievement rate of emergency medicine inhabitants in airway management improved enhanced essentially subsequent to finishing anaesthesiology turn. There was a slightly higher rate of quick sequence intubation in the postapneic oxygenation groups (preapneic oxygenation 6.4%; postapneic oxygenation 9.1%). The majority of patients intubated in both groups were men (preapneic oxygenation 72.3%; postapneic oxygenation 63.5%). A higher percentage of patients in the preapneic oxygenation group had a Cormack-Lehane grade III or worse view (23.2% versus 11.8%). Anaesthesiology turns should be considered as an essential component of emergency medicine training programs. A collateral curriculum of this nature should also focus on the acquisition of skills in airway management.
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Affiliation(s)
- Yong Mao
- Department of Intensive Care Unit, Shanghai 9th People's Hospital, Shanghai Jiao Tong University, School of Medicine Shanghai 200011, China
| | - Zong-He Qin
- Department of Intensive Care Unit, Shanghai 9th People's Hospital, Shanghai Jiao Tong University, School of Medicine Shanghai 200011, China
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Abstract
An immediate, effective team response is needed in order to properly cater to the needs of trauma patients. This paper aims to review some of the strategies that can be implemented in Emergency Departments to reduce errors and improve decision-making in major trauma. It focuses on the phase prior to the patient’s arrival, and in the first few minutes afterwards – as there is evidence that an organised response at this point creates the ideal conditions for all subsequent activity, such as transfer of the patient for further imaging and the requirement for emergency surgery.
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Affiliation(s)
- S Horne
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - JE Smith
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
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Role of anesthesiology curriculum in improving bag-mask ventilation and intubation success rates of emergency medicine residents: a prospective descriptive study. BMC Emerg Med 2011; 11:8. [PMID: 21676271 PMCID: PMC3125215 DOI: 10.1186/1471-227x-11-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Accepted: 06/16/2011] [Indexed: 11/23/2022] Open
Abstract
Background Rapid and safe airway management has always been of paramount importance in successful management of critically ill and injured patients in the emergency department. The purpose of our study was to determine success rates of bag-mask ventilation and tracheal intubation performed by emergency medicine residents before and after completing their anesthesiology curriculum. Methods A prospective descriptive study was conducted at Nikoukari Hospital, a teaching hospital located in Tabriz, Iran. In a skills lab, a total number of 18 emergency medicine residents (post graduate year 1) were given traditional intubation and bag-mask ventilation instructions in a 36 hour course combined with mannequin practice. Later the residents were given the opportunity of receiving training on airway management in an operating room for a period of one month which was considered as an additional training program added to their Anesthesiology Curriculum. Residents were asked to ventilate and intubate 18 patients (Mallampati class I and ASA class I and II) in the operating room; both before and after completing this additional training program. Intubation achieved at first attempt within 20 seconds was considered successful. Successful bag-mask ventilation was defined as increase in ETCo2 to 20 mm Hg and back to baseline with a 3 L/min fresh gas-flow and the adjustable pressure limiting valve at 20 cm H2O. An attending anesthesiologist who was always present in the operating room during the induction of anesthesia confirmed the endotracheal intubation by direct laryngoscopy and capnography. Success rates were recorded and compared using McNemar, marginal homogeneity and paired t-Test tests in SPSS 15 software. Results Before the additional training program in the operating room, the participants had intubation and bag-mask ventilation success rates of 27.7% (CI 0.07-0.49) and 16.6% (CI 0-0.34) respectively. After the additional training program in the operating room the success rates increased to 83.3% (CI 0.66-1) and 88.8% (CI 0.73-1), respectively. The differences in success rates were statistically significant (P = 0.002 and P = 0.0004, respectively). Conclusions The success rate of emergency medicine residents in airway management improved significantly after completing anesthesiology rotation. Anesthesiology rotations should be considered as an essential component of emergency medicine training programs. A collateral curriculum of this nature should also focus on the acquisition of skills in airway management.
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Winton J, Celenza A, Jackson T. Improving documentation of endotracheal intubation in an adult emergency department. Emerg Med Australas 2010; 20:488-93. [PMID: 19125827 DOI: 10.1111/j.1742-6723.2008.01134.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the effect of an educational intervention and documentary pro forma on the adequacy of documentation of intubation in an adult ED. METHODS A structured medical record review was performed before and after a multi-pronged educational programme and introduction of a specifically designed guide to documentation. Records were assessed for adequacy of documentation by the presence or absence of predetermined elements. Analysis focused on five aspects considered to be most important for future clinical care: drugs and doses used, grade of view, size of endotracheal tube, confirmation of placement and adverse events/difficulties encountered. RESULTS Sixty-one and sixty-eight charts were included in the pre-intervention and post-intervention groups, respectively. The drugs and doses used were documented in 92% and 93%. The endotracheal tube size was recorded 82% and 91% of the time. Grade of laryngoscopy was documented in 35% and 46%. Confirmation of endotracheal tube placement was 69% and 84%. Presence or absence of adverse events was recorded in 37% and 54%. All five elements were present in 8.2% and 25% of medical records. CONCLUSION Documentation improved slightly following the intervention, but was still unsatisfactory. We believe that to achieve an adequate level of documentation in the medical record for an episode of intubation, there needs to be a formal and structured mechanism, either via mandatory use of a specifically designed form and/or by participation in an organized data registry.
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Affiliation(s)
- James Winton
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Armstrong B, Reid C, Heath P, Simpson H, Kitching J, Nicholas J, Chan L, Taylor J, Rush H. Rapid sequence induction anaesthesia: a guide for nurses in the emergency department. Int Emerg Nurs 2009; 17:161-8. [PMID: 19577203 DOI: 10.1016/j.ienj.2008.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 11/01/2008] [Accepted: 11/24/2008] [Indexed: 11/17/2022]
Abstract
Emergency rapid sequence induction (RSI) anaesthesia is the cornerstone of emergency airway management performed on patients in the emergency department (ED). The Royal College of Anaesthetists has stated that anaesthesia should not proceed without a skilled, dedicated assistant. It is essential that ED nurses are educated, skilled and competent to assist with RSI in the ED.
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Affiliation(s)
- Bruce Armstrong
- Department of Emergency Medicine, Basingstoke and North Hampshire Hospital Trust, Aldermaston Road, Basingstoke RG24 9NA, UK.
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Pandit JJ. Gambling with ethics? A statistical note on the Poisson (binomial) distribution. Anaesthesia 2008; 63:1163-6. [DOI: 10.1111/j.1365-2044.2008.05729.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW This review focuses on recent knowledge in areas of anaesthesia expertise which are indispensable to intensive care unit management, including airway management, vascular access, regional analgesia and the treatment of status asthmaticus and status epilepticus. RECENT FINDINGS Etomidate as the sole agent for intubation in the intensive care unit has a 90% success rate, while in a prehospital setting, the addition of succinylcholine to etomidate results in a 99% success rate. In determining successful intubation, capnography and laryngoscopic/fibreoptic visualization are superior to auscultation, while auscultation is as effective as the self-inflating bulb or transillumination with the lightwand. The dorsalis pedis artery is an effective alternative to radial artery cannulation, while arterial cannulation itself can result in major adverse effects if complications arise. Ultrasound guidance in the placement of central catheters results in an improved insertion success rate. Internal jugular and subclavian lines have similar risk of haemothorax or pneumothorax, while subclavian lines are associated with the lowest incidence of infection. Midazolam, thiopentone and propofol have all been found to be efficacious in terminating refractory status epilepticus, with thiopentone resulting in a lower incidence of breakthrough seizures or treatment failure but an increased incidence of hypotension. Inhalational anaesthesia using isoflurane or desflurane has also been found to be successful in refractory status epilepticus. In the management of status asthmaticus, limiting minute volume while tolerating hypercapnia and acidosis as well as the use of inhalational anesthesia have proven effective strategies in a number of refractory cases. SUMMARY The anaesthesiologist's unique knowledge and skills are ideally suited to the practical management of patients in a critical care setting as well as in the treatment of the critical phases of many illnesses.
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Affiliation(s)
- Niall Evans
- Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town, South Africa.
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Brown AFT. Advanced airway management in the emergency department: Finally moving on from provenance to providence. Emerg Med Australas 2007; 19:185-7. [PMID: 17564682 DOI: 10.1111/j.1742-6723.2007.00971.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ollerton JE, Parr MJA, Harrison K, Hanrahan B, Sugrue M. Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review. Emerg Med J 2006; 23:3-11. [PMID: 16373795 PMCID: PMC2564122 DOI: 10.1136/emj.2004.020552] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Revised: 12/21/2004] [Accepted: 02/04/2005] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. OBJECTIVES To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. SEARCH STRATEGY AND METHODOLOGY Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.
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Affiliation(s)
- J E Ollerton
- Department of Trauma, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia.
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Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Trauma and Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
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Klein M, Weksler N, Kaplan DM, Weksler D, Chorny I, Gurman GM. Emergency percutaneous tracheostomy is feasable in experienced hands. Eur J Emerg Med 2004; 11:108-12. [PMID: 15028902 DOI: 10.1097/00063110-200404000-00011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Percutaneous dilatational tracheostomy in experienced hands takes only a few minutes. We describe six patients, including two trauma patients, in whom emergency percutaneous tracheostomy was rapidly and successfully performed under conditions of the imminent loss of airway and inability to intubate the patient. As this procedure is safe and can be performed easily by experienced personnel, we propose its addition to the armamentarium of emergency airway management.
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Affiliation(s)
- Moti Klein
- Division of Anesthesiology and Critical Medicine, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of The Negev, Beer Sheva, 84101, Israel
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Abstract
The importance of establishing and maintaining a patent airway is a well-recognized principle in the resuscitation of all trauma victims. Many currently available guidelines for airway management in trauma patients have been aimed largely at anaesthetists or those with anaesthetic training. Typically they concen trate on either those patients who require intubation, with techniques to use when this fails, or those in whom little intervention beyond facemask oxygen is required. In reality, clinicians with varying degrees of skill will be faced with managing the trauma patient’s airway and many will not be able to safely attempt tracheal intubation. A pragmatic approach to airway assessment and management is presented that recognizes the variation in skills between clinicians. We also suggest that the role of supraglottic airway devices should now be recognized by all clinicians involved with airway management, particularly those not skilled in tracheal intubation and they should become an integral part of airway management.
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Evans N, Skowno J, Hodgson E. Curr Opin Anaesthesiol 2003; 16:401-407. [DOI: 10.1097/00001503-200308000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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