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07/09/2016

Airway: S'y pencher avec sérieux

Emergency airway management – by whom and how ?

Sollid SJ et Al. Acta Anaesthesiol Scand. 2016 Oct;60(9):1185-7

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Encore une publication qui insiste sur la formation à la gestion des voies aériennes et au maintien de ses compétences. Ceci n'est pas innée et s'impose tout d'abord non seulement aux praticiens peu confrontés à cette exercice, en première ligne les médecins urgentistes, mais aussi aux médecins anesthésistes compte tenu de l'essor de l'anesthésie loco-régionale et l'emploi de dispositifs supra-glottique. A lire et relire, ainsi que les références.

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Procedures for advanced airway management are important for maintaining basic life functions in the unconscious patient, and can be lifesaving in critically ill or injured patients. In Acta Anaesthesiologica Scandinavica, a working group from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) presents updated clinical guidelines on pre-hospital airway management.[1] The recommendations from the working group are important statements in the long-lasting quest to ensure that advanced airway management is managed safely pre-hospital at the right level of competence.

Technically, many of the procedures for advanced airway management of the average patient in controlled situations are easy to learn. Yet, a German study found that at least 200 intubation attempts were required to reach a 95% success rate.[2] The challenge, however, lies in assessing and managing the difficult airway cases. Emergency physicians with anaesthesiology background seem to be better at predicting difficult intubations than emergency physicians with other backgrounds, in addition to having significantly lower incidence of intubation problems and more experience in decisions on whether to intubate.[3]

Data from the UK show that the majority of complications in airway management occur in the emergency department and the intensive care unit. One of the reasons is the relatively low exposure to such procedures in these settings.[4] Studies on pre-hospital airway management also indicate that the rate of complications in this setting is high, and also that it is greatly dependent on the competence of the provider.[5] There is sufficient evidence to support that pre-hospital advanced airway management in the hands of trained anaesthesiologists is a safe procedure.[6-8] However, as other authors have pointed out, being a proficient provider of airway management is not equivalent with being an anaesthesiologist.[9] The combination of competencies to assess the situation, practical skills and ability to manage complications are more important than the name of the provider's speciality. In a physician-staffed helicopter emergency medical service in the UK, where doctors are a mix of anaesthesiologists and emergency physicians, the success rates are still high and complications are low.[10] This is probably related to the strict training and highly standardised operating procedures that all doctors must adhere to.

Based on this, advanced airway management seems to be safe if the providers have a large volume of clinical experience (anaesthesiologists) or alternatively, operate under strict clinical guidance and protocol rule (non-anaesthesiologists). Intuitively, a combination of both could probably improve safety further and would be useful in clinical environments, and particularly when airway management occurs as unplanned events with little or no time for individual planning and screening of the patient.

The most recent consensus-based European Guidelines for Postgraduate Training in Anaesthesiology recommend the change from duration of training and number of procedures into competence-based training.[11] These competences include advanced airway management skills. Some of this training can be done in simulation settings, but simulation cannot replace real-life situations.[12, 13] Once learnt, competences must be maintained. That requires regular exposure to the procedure. As the use of laryngeal masks and regional blocks increases at the expense of anaesthesia procedures including endotracheal intubation, the training opportunities for all providers, including anaesthesia personnel is being reduced. That is one of the reasons why the Section and Board of Anaesthesiology of the European Union of Medical Specialists recommended a multispecialty approach to emergency medicine.[14] Like the Scandinavian Society of Anaesthesiology and Intensive Care recommended in 2010,[15] the European Society of Anaesthesiology is increasingly using the term ‘Critical Emergency Medicine’ for the part of the anaesthesiology speciality that all anaesthesiologists should command.

A Nordic working group published a literature review in 2008 on pre-hospital airway management, and proposed an evidence-based guideline.[16] This position paper concludes unanimously that pre-hospital emergency airway management in the appropriate patient groups should be achieved by rapid sequence induction and endotracheal intubation, provided the physician is an anaesthesiologist. Other providers should treat the same patient group in the lateral trauma recovery position and if necessary, provide assisted bag-valve-mask ventilation. Supraglottic airway devices were recommended for non-anaesthesiologists in cardiac arrest with a need for supine positioning of the patient, and as a backup device for anaesthesiologists. These findings have been reaffirmed in the new SSAI clinical practice guideline published in August issue.[1]

A similar paper concerning Scandinavian clinical practice guidelines on general anaesthesia for emergency situations underlines the dangers associated with administering anaesthesia outside the operating theatre. They too advocate that anaesthesia for emergency patients should be given by, or under very close supervision by, experienced anaesthesiologists, and stress that problems with the airway are to be anticipated.[17]

Emergency airway management outside the operating theatres carries a high risk of difficult intubation, in a recent study 10.3%, and these patients have a high risk of complications.[18] This demonstrate the need for particular vigilance in and training for these settings, and provides another argument for using supraglottic approaches for those patients in the hands of non-anaesthesiologists. A recent report from the Johns Hopkins Hospital describes a successful attempt to mitigate difficult airway situations arising within this highly specialised hospital. By the formation of a difficult airway response team, the researchers conquered difficult airway situations which until the intervention ranked among the top five adverse events in Maryland.[19]

In conclusion, emergency airway management carries a high risk of patient injury, even among highly trained and skilled anaesthesiologists. Airway management can be learned, and emergency airway handling can be performed with maintained safety also by non-anaesthesiologists, provided they operate in a highly supervised and algorithm-based environment.[9] In this light, the emerging new emergency medical specialty in the Scandinavian countries is of concern, if these acute or emergency physicians are supposed to perform emergency airway procedures independent of their anaesthesiologist colleagues. Whoever manages the compromised airway in the pre-hospital setting is required to do so with the highest level of quality, attainable through a combination of clinical experience and clinical governance. It is difficult to see how this can be achieved and maintained outside the specialty of anaesthesiology. In the end, this is a matter of patient safety, not competition for airways.

| Tags : airway

31/08/2016

Echo et voies aériennes: Mais oui, à maîtriser

The Role of Airway and Endobronchial Ultrasound in Perioperative Medicine

Vortrua J et Al. Biomed Res Int. 2015; 2015: 754626

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Certainement UN APPORT IMPORTANT à la gestion des voies aériennes et de la ventilation non seulement dans les blocs opératoires mais dans les situations critiques y compris hors de l'hôpital.

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Recent years have witnessed an increased use of ultrasound in evaluation of the airway and the lower parts of the respiratory system. Ultrasound examination is fast and reliable and can be performed at the bedside and does not carry the risk of exposure to ionizing radiation. Apart from use in diagnostics it may also provide safe guidance for invasive and semi-invasive procedures. Ultrasound examination of the oral cavity structures, epiglottis, vocal cords, and subglottic space may help in the prediction of difficult intubation. Preoperative ultrasound may diagnose vocal cord palsy or deviation or stenosis of the trachea. Ultrasonography can also be used for confirmation of endotracheal tube, double-lumen tube, or laryngeal mask placement. This can be achieved by direct examination of the tube inside the trachea or by indirect methods evaluating lung movements. Postoperative airway ultrasound may reveal laryngeal pathology or subglottic oedema. Conventional ultrasound is a reliable real-time navigational tool for emergency cricothyrotomy or percutaneous dilational tracheostomy. Endobronchial ultrasound is a combination of bronchoscopy and ultrasonography and is used for preoperative examination of lung cancer and solitary pulmonary nodules. The method is also useful for real-time navigated biopsies of such pathological structures.

 

 

| Tags : airway

29/08/2016

Echographie: Un outil pour la gestion des VAS

Role of upper airway ultrasound in airway management

Osman A. et Al. Osman and Sum Journal of Intensive Care (2016) 4:52 

 

Upper airway ultrasound is a valuable, non-invasive, simple, and portable point of care ultrasound (POCUS) for evaluation of airway management even in anatomy distorted by pathology or trauma. Ultrasound enables us to identify important sonoanatomy of the upper airway such as thyroid cartilage, epiglottis, cricoid cartilage, cricothyroid membrane, tracheal cartilages, and esophagus. Understanding this applied sonoanatomy facilitates clinician to use ultrasound in assessment of airway anatomy for difficult intubation, ETT and LMA placement and depth, assessment of airway size, ultrasound-guided invasive procedures such as percutaneous needle cricothyroidotomy and tracheostomy, prediction of postextubation stridor and left double-lumen bronchial tube size, and detecting upper airway pathologies. Widespread POCUS awareness, better technological advancements, portability, and availability of ultrasound in most critical areas facilitate upper airway ultrasound to become the potential first-line non-invasive airway assessment tool in the future.

| Tags : intubation

14/07/2016

Soleil et chaleur: plutôt gênant

Prehospital Endotracheal Intubation in Warm Climates: Caution is Required

Daniel Y. et Al. J Emerg Med. 2016 Jul 2. pii: S0736-4679(16)30264-5. doi: 10.1016/j.jemermed.2016.06.006.

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Une chose bien connue et très clairement explicitée:

Lire également ce post

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BACKGROUND:

Out-of-hospital endotracheal intubation is a frequent procedure for trauma care. Nevertheless, in warm climates, sunlight and heat can interfere with the flow of the usual procedure. They can affect the equipment and hinder the operator. There are few data on this issue. The presentation of this case highlights three common complications that may occur when intubating under a hot and bright sun.

CASE REPORT:

A 23-year-old man had a car accident in Djibouti, at 11:00 a.m., in broad sunlight. The heat was scorching. Due to a severe head trauma, with a Glasgow Coma Scale score of 8, it was decided to perform an endotracheal intubation. The operator faced three problems: the difficulty of seeing inside the mouth in the bright sunlight, the softening of the tube under the influence of the heat, and the inefficiency of colorimetric CO2 detectors in the warm atmosphere in confirming the proper endotracheal tube placement.

WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?:

Solutions are simple, but must be known and planned ahead, prior to beginning the procedure: Putting a jacket over his head while doing the laryngoscopy would solve the problem of dazzle; adjuncts like a stylet or gum elastic bougie have to be used at the outset to fix the softening problem; alternative methods to exhaled CO2 detection, such as the syringe aspiration technique, to confirm the proper tube placement, should be available.

22/06/2016

AL pour intuber: A ressortir de l'oubli

The Myth of Rescue Reversal in “Can’t Intubate, Can’t Ventilate” Scenarios

Naguib N. et Al. Anesth Analg. 2016 Jul;123(1):82-92

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Ce travail met en avant l'insuffisance des démarches d'antagonisation pour restaurer une ventilation adéquate dans les situations de CICV. En ce qui concerne la gestion des voies aériennes en situation tactique, le principe de la préservation de la ventilation spontanée lors de l'accès aux voies aériennes mérite d'être rappelé. Si la réalisation d'une induction en séquence rapide reste la référence, en cas de difficulté prévisible le recours à une anesthésie locale doit être préférée (lire ce post).

images?q=tbn:ANd9GcT3-CT1svI9dwqEWJ_jPxF47bj-a1A40-C1ybrXzCo3Kmtlf01-Yw

Ceci est parfaitement stipulé dans les RFE "Sédation et analgésie en structure d’urgence"  dont on rappelle après la présentation de l'abstract les termes de la question N3.

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BACKGROUND:

An unanticipated difficult airway during induction of anesthesia can be a vexing problem. In the setting of can't intubate, can't ventilate (CICV), rapid recovery of spontaneous ventilation is a reasonable goal. The urgency of restoring ventilation is a function of how quickly a patient's hemoglobin oxygen saturation decreases versus how much time is required for the effects of induction drugs to dissipate, namely the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade. It has been suggested that prompt reversal of rocuronium-induced neuromuscular blockade with sugammadex will allow respiratory activity to recover before significant arterial desaturation. Using pharmacologic simulation, we compared the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade in normal, obese, and morbidly obese body sizes in this life-threatening CICV scenario. We hypothesized that although neuromuscular function could be rapidly restored with sugammadex, significant arterial desaturation will occur before the recovery from unresponsiveness and/or central ventilatory depression in obese and morbidly obese body sizes.

METHODS:

We used published models to simulate the duration of unresponsiveness and ventilatory depression using a common induction technique with predicted rates of oxygen desaturation in various size patients and explored to what degree rapid reversal of rocuronium-induced neuromuscular blockade with sugammadex might improve the return of spontaneous ventilation in CICV situations.

RESULTS:

Our simulations showed that the duration of neuromuscular blockade was longer with 1.0 mg/kg succinylcholine than with 1.2 mg/kg rocuronium followed 3 minutes later by 16 mg/kg sugammadex (10.0 vs 4.5 minutes). Once rocuronium neuromuscular blockade was completely reversed with sugammadex, the duration of hemoglobin oxygen saturation >90%, loss of responsiveness, and intolerable ventilatory depression (a respiratory rate of ≤4 breaths/min) were dependent on the body habitus and duration of oxygen administration. There is a high probability of intolerable ventilatory depression that extends well beyond the time when oxygen saturation decreases <90%, especially in obese and morbidly obese patients. If ventilatory rescue is inadequate, oxygen desaturation will persist in the latter groups, despite full reversal of neuromuscular blockade. Depending on body habitus, the duration of intolerable ventilatory depression after sugammadex reversal may be as long as 15 minutes in 5% of individuals.

CONCLUSIONS:

The clinical management of CICV should focus primarily on restoration of airway patency, oxygenation, and ventilation consistent with the American Society of Anesthesiologist's practice guidelines for management of the difficult airway. Pharmacologic intervention cannot be relied upon to rescue patients in a CICV crisis.

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Question 3 - Intubation sous ISR et sous AL : Quelles sont les modalités de réalisation d’une sédation et/ou d’une analgésie pour l’intubation trachéale ?

Les experts recommandent d’administrer une sédation pour toutes les indications de l’intubation trachéale, excepté chez le patient en arrêt cardiaque qui ne nécessite pas de sédation. Lorsque l’intubation trachéale est présumée diffi cile, il est possible d’effectuer une anesthésie locale réalisée de proche en proche, associée ou non à une sédation légère et titrée par voie générale

L’utilisation de médicaments anesthésiques lors de l’intubation trachéale a pour but de faciliter le geste et d’assurer le confort du patient. Cette sédation doit être rapidement réversible pour restaurer une ventilation effi cace en cas de diffi culté d’intubation. Le risque d’inhalation bronchique doit être minimisé au cours de la procédure et ce d’autant que les patients sont considérés comme ayant un estomac plein.

Les experts recommandent d’utiliser les techniques d’intubation en séquence rapide (ISR) associant un hypnotique d’action rapide (étomidate ou kétamine) et un curare d’action brève (succinylcholine) ........................................................

Lorsque l’intubation trachéale est présumée difficile, le protocole recommandé par les experts pour une intubation vigile est le suivant : - Lidocaïne entre 2 et 5% en pulvérisation de proche en proche - Complément de sédation intraveineuse pour intubation vigile : • midazolam : 1 mg par 1 mg IV • associé ou non à de la morphine : 2 mg par 2 mg IV

INTPreH.jpg

 

05/06/2016

Echographie pour l'intubation: Plutôt oui.

Tracheal ultrasonography and ultrasonographic lung sliding for confirming endotracheal tube placement: Speed and Reliability

Karacabey S. et Al. Am J Emerg Med. 2016 Jan 26. pii: S0735-6757(16)00037-1. doi: 10.1016/j.ajem.2016.01.027.

BACKGROUND:

In this study we aimed to evaluate the success of ultrasonography (USG) for confirming the tube placement and timeliness by tracheal USG and ultrasonographic lung sliding in resuscitation and rapid sequence intubation.

MATERIALS AND METHODS:

This study was a prospective, single-center, observational study conducted in the emergency department of a tertiary care hospital. Patients were prospectively enrolled in the study. Patients who went under emergency intubation because of respiratory failure, cardiac arrest or severe trauma included in the study. Patients with severe neck trauma, neck tumors, history of neck operation or tracheotomy and under 18years old were excluded from the study.

RESULTS:

A total of 115 patients included in the study. The mean age was 67.2±17.1 with age 16-95years old. Among 115 patients 30 were cardiac arrest patients other 85 patients were non-cardiac arrest patients intubated with rapid sequence intubation. The overall accuracy of the ultrasonography was 97.18% (95% CI, 90.19-99.66%), and the value of kappa was 0.869 (95% CI, 0.77-0.96), indicating a high degree of agreement between the ultrasonography and capnography. The ulrasonography took significantly less time than capnography in total.

DISCUSSION:

Ultrasonography achieved high sensitivity and specificity for confirming tube placement and results faster than end-tidal carbon dioxide. Ultrasonography is a good alternative for confirming the endotracheal tube placement. Future studies should examine the use of ultrasonography as a method for real-time assessment of endotracheal tube placement by emergency physicians with only basic ultrasonographic training.

| Tags : airway, échographie

24/01/2016

Succinylcholine et frigo: Non fondé ?

Froid et suxaméthonium : une recommandation non fondée

Dewachter P et AL. Ann. Fr. Med. Urgence DOI 10.1007/s13341-015-0600-1

Morceaux choisis:

L’Agence nationale de sécurité du médicament et des produits de santé (ANSM) a publié en 2012 une recommandation destinée aux médecins anesthésistes-réanimateurs et urgentistes décrivant les conditions d’utilisation du chlorure de suxaméthonium. .......Cette recommandation faisait suite à une enquête rétrospective de pharmacovigilance sur les réactions allergiques induites par les curares qui mettait en évidence une augmentation des notifications de réactions allergiques attribuées au suxaméthonium........Néanmoins, l’hypothèse émise par l’ANSM ne résiste pas à l’évaluation scientifique. En effet, aucune étude n’a démontré que le suxaméthonium conservé à température ambiante favorise la survenue d’une réaction allergique, ce qui avait déjà été souligné lors de la publication de cette recommandation..........................En revanche, depuis 20 ans, plusieurs équipes européennes et nord-américaines ont confirmé la stabilité des solutions de chlorure de suxaméthonium à température ambiante ou lors de variations extrêmes de température................... La succinylcholine (50 mg/mL) préservée dans l’ampoule est stable pendant deux mois à température ambiante (25°C) [5] alors que la solution à 20 mg/mL reste stable au moins sept jours après exposition à des variations extrêmes de température (de -6°C à +54°C).......................Par ailleurs, la solution de succinylcholine (20 mg/mL) conservée dans une seringue en plastique est stable trois mois à 25°C et deux mois à 40°C . Enfin, la stabilité de la succinylcholine stockée à bord d’ambulances, respectivement pendant sept mois [8] et un an , a été évaluée après exposition aux variations climatiques auxquelles ces équipes sont exposées. La succinylcholine (20 mg/mL) est stable pendant environ trois mois quand elle est soumise à des températures moyennes variant de -9°C à +32°C [8] alors que la solution à 100 mg/mL est stable pendant un peu plus d’un mois quand elle est exposée de -8°C à +36°C. D’autres études ont également confirmé la stabilité de la succinylcholine (10 mg/ml) dans une seringue en plastique pendant sept jours [9] et pendant au moins cinq mois, quand celle-ci est conservée dans l’ampoule (20 et 50 mg/ml) ..........Plus récemment, la stabilité de la succinylcholine à température ambiante (25°C) a été confirmée par l’ANSM pour qui les résultats obtenus sont « conformes aux spécifications à péremption décrites dans le dossier d’AMM................Ce rapport de conclure que « les données relatives à la qualité ne semblent donc pas être en mesure d’expliquer l’augmentation des réactions anaphylactiques sur la période étudiée............Le turn-over prévisible de l’utilisation du suxaméthonium stocké à température ambiante rend ainsi son utilisation possible par les équipes de Samu. En effet, l’éventuelle morbidité – voire mortalité – induite par cette recommandation ne peut être occultée. Nombreux sont les patients qui devant bénéficier d’une induction à séquence rapide, ont été intubés sans curare par les équipes qui ne disposaient pas d’un réfrigérateur à bord alors que l’appréciation de la balance risque/ bénéfice penche en faveur de l’utilisation du suxaméthonium dans cette situation clinique

 

 

Gammon DL, et al (2008) Alteration in prehospital drug concentration after thermal exposure. Am J Emerg Med 26:566–73.

Agence Nationale de Sécurité du Médicament et des Produits de Santé (2013) Enquête officielle de pharmacovigilance relative aux réactions anaphylactiques liées à l’utilisation des curares. 21 mai 2013. 

| Tags : intubation

23/01/2016

Maîtriser l'airway +++, entre autres

Augmentation of point of injury care: Reducing battlefield
mortality—The IDF experience

Benov A. et Al. Injury. 2015 Nov 18. pii: S0020-1383(15)00697-X. doi: 10.1016/j.injury.2015.10.078.

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Une publication particulièrement intéressante car elle émane de collègues militaires qui interviennent dans un contexte très particulier de prise en charge de blessés tels qu'on peut les rencontrer en opérations extérieures mai dans un contexte de réseau de traumatologie civile puisque que les hôpitaux de recueil de ces blessés sont les hôpitaux civils. Les données présentées ne portent que sur la prise en charge de combattants.

Un des points analysé est la performance des équipes dans certains gestes considérés comme essentiel, notamment la gestion des voies aériennes. Comme dans l'armée française l'intubation orotrachéale et la criciothyrotomie représentent les deux procédures mises en oeuvre par des médecins. Manifestement, il existe une grande maîtrise de la coniotomie alors que celle de l'Intubation est moins évidente: 41% de succès et une moyenne de 2 tentatives. Ceci reste problématique lorsque la prise en charge des blessés se fait loin d'un trauma center et qu'il faut envisager la gestion de ces voies aériennes et l'initiation d'une ventilation pendant plusieurs heures (jours ?). Pour ces raisons et même si la probabilité d'être confronté à une telle situation est faible, ce travail rapporte les 2/3 des blessés ne sont pas urgent et que 5% seulement des nécessitent un geste sur les voies aériennes, il s'agit d'un point fondamental en matière de réduction de morts indues.

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STUDY OBJECTIVE:

In 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled "My Brother's Keeper" was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical carehas evolved due "My Brother's Keeper" between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014).

METHODS:

Records of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis.

RESULTS:

The plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively.

CONCLUSIONS:

Significant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.

| Tags : airway

17/12/2015

Médicaliser: Pour faire quoi ?

Doctor on board ? What is the optimal skill-mix in military pre-hospital care ?

Calderbank P. et Al.  Emerg Med J (2010). doi:10.1136/emj.2010.097642

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Le document proposé à la lecture porte sur l'intérêt de la présence d'un médecin dans la plus avancée des structures medevac qui existe actuellement: Les MERT-E des anglais. Seule 1 medevac sur 5 justifiait la présence d'un médecin. L'intervention la plus fréquemment réalisée a été l'intubation/induction en séquence rapide. Bien loin devant d'autres gestes comme la thoracostomie ou le drainage thoracique. Ceci étant dit ce constat est fait dans un contexte spécifique afghan qui ne correspond pas aux opérations actuelles où les délais de prise en charge chirurgicales peuvent être long. Cette pratique est donc essentielle à maîtriser et procède d'une véritable stratégie de formation, avec une rythmicité semestrielle,  débutée dès la formation initiale, associant un parcours structuré de mises à jour technique personnelle (passage en bloc opératoire, participation à des ateliers sur simulateurs de taches) et collective. Il s'agit d'un exemple parmi d'autres où une implication personnelle forte doit être présente.

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Background

In a military setting, pre-hospital times may be extended due to geographical or operational issues. Helicopter casevac enables patients to be transported expediently across all terrains. The skill-mix of the prehospital team can vary. Aim To quantify the doctors’ contribution to the Medical Emergency Response TeameEnhanced (MERT-E).

Methods

A prospective log of missions recorded urgency category, patient nationality, mechanism of injury, medical interventions and whether, in the crew’s opinion, the presence of the doctor made a positive contribution.

Results

Between July and November 2008, MERT-E flew 324 missions for 429 patients. 56% of patients carried were local nationals, 35% were UK forces. 22% of patients were T1, 52% were T2, 21.5% were T3 and 4% were dead. 48% patients had blast injuries, 25% had gunshot wounds, 6 patients had been exposed to blast and gunshot wounds. Median time from take-off to ED arrival was 44 min. A doctor flew on 88% of missions. It was thought that a doctor’s presence was not clinically beneficial in 77% of missions. There were 62 recorded physician’s interventions: the most common intervention was rapid sequence induction (45%); other interventions included provision of analgesia, sedation or blood products (34%), chest drain or thoracostomy (5%), and pronouncing life extinct (6%).

Conclusion

MERT-E is a high value asset which makes an important contribution to patient care. A relatively small proportion of missions require interventions beyond the capability of well-trained military paramedics; the indirect benefits of a physician are more difficult to quantify.

| Tags : airway

26/11/2015

Intubation difficile: Reco UK

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

overviewweb.png

Clic sur l'image pour accéder au document

| Tags : intubation, airway

22/11/2015

Laryngoscopie directe: LA BASE

Videolaryngoscopy in trauma

Eggleton A. Anaesthesia 2015, 70, 1454–1466

In their paper on airway management in cervical spine injury [1], focusing on videolaryngoscopy, Duggan and Griesdale mention characteristics that predispose to failure of videolaryngoscopy, including anatomical abnormality, local scarring, radiotherapy, and airway masses. An additional factor worth considering, especially in the context of trauma, is the impact of oropharyngeal blood on the videolaryngoscopic view, which can obscure the larynx or camera lens and obstruct the light source, reducing illumination. Recent personal experiences with a McGrath MAC videolaryngoscope (Aircraft Medical, Edinburgh, UK) found that dried blood lining the oropharynx reduced reection, producing a dull on-screen image, requiring conversion to direct laryngosc opy. It seems likely that videolaryngoscopy will replace direct laryngoscopy as the standard method of intubation, but the auth ors are correct in saying it will remain necessary to maintain ski lls in both techniques.

Reference
1. Duggan LV, Griesdale DEG. Secondary cervical spine injury during airway management: beyond a one-size-fits-all
approach. Anaesthesia 2015; 70: 76973

| Tags : airway, intubation

12/11/2015

IOT: Affaire de tous et pas de spécialiste

A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013

Pugh HEJ, et al. J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2014-000271

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Parmi les enjeux de la médicalisation de l'avant, ou en d'autres termes du prolonged field care, il y a la maîtrise de la gestion des voies aériennes, notamment l'intubation et la coniotome. Ce document qui analyse tous les blessés ayant bénéficié d'une manoeuvre avancée avant leur prise en charge au role 3 de Camp Bastion.Très clairement la prise en charge des blessés par des personnels expert de part leur emploi en UK permet l'obtention de 100 % de réussite alors que ce geste conduit par les équipes US n'atteint un taux de succès que de 64%. Les équipes UK n'ont pas eu besoin d'avoir recours à la coniotomie. Cette dernière est réalisée à 14 reprises par les équipes US avec 1 seul échec vrai. Les vraies complications étaient une intubation sélective à 3 reprises et un placement oesophagien. Notons la place relativement restreinte du tube laryngé de King. Une fois de plus il faut insister sur la nécessité de maîtrise de l'abord trachéal par tout personnel médical. Alors si cette éventualité n'est pas fréquente, les conditions actuelles avec les éloignements et la durée des MEDEVAC font qu'acquérir et entretenir cette maîtrise  est fondamental et que chacun soit conscient de cette nécessité. 

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Objectives

Airway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on cricothyroidotomies and supraglottic airway devices in combat casualties prior to admission to a Role 3 Hospital in Afghanistan.


Methods

This was a retrospective review of all casualties who required advanced airway management prior to arrival at the Role 3 Hospital, Bastion, Helmand Province over a 30-week period identified by the US Joint Theatre Trauma Registry. The notes and relevant X-rays were analysed. The opinions of US and UK clinical Subject Matter Experts (SME) were then sought.

Results

Fifty-seven advanced airway interventions were identified. 45 casualties had attempted intubations, 37 (82%) were successful and of those who had failed intubations, one had a King LT Airway (supraglottic device) and seven had a rescue cricothyroidotomy. The other initial advanced airway interventions were five attempted King LT airways and seven attempted cricothyroidotomies. In total, 14 cricothyroidotomies were performed; in this group, there were nine complications/significant events.

Intubation.jpg


Conclusions

The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to "ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield".

| Tags : airway

12/09/2015

Abord trachéal: Point sur l'équipement

Equipment and strategies for emergency tracheal access in the adult patient

Hamaekers AE et Al; Anaesthesia, 2011, 66 (Suppl. 2), pages 65–80

 

The inability to maintain oxygenation by non-invasive means is one of the most pressing emergencies in anaesthesia and emergency care. To prevent hypoxic brain damage and death in a ‘cannot intubate, cannot oxygenate’ situation, emergency percutaneous airway access must be performed immediately. Even though this emergency is rare, every anaesthetist should be capable of performing an emergency percutaneous airway as the situation may arise unexpectedly. Clear knowledge of the anatomy and the insertion technique, and repeated skill training are essential to ensure completion of this procedure rapidly and successfully. Various techniques have been described for emergency oxygenation and several commercial emergency cricothyroidotomy sets are available. There is, however, no consensus on the best technique or device. As each has its limitations, it is recommended that all anaesthetists are skilled in more than one technique of emergency percutaneous airway. Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome.

| Tags : airway

02/08/2015

CICO: Un cours en ligne

 

VortexCognitiveAidUpdated2014_3.jpg

clic sur l'image pour accéder au site

| Tags : airway

26/07/2015

Laryngoscope: Le manche compte

The effect of laryngoscope handle size on possible endotracheal intubation success in university football, ice hockey, and soccer players.

Delaney JS et Al. Clin J Sport Med. 2012 Jul;22(4):341-8

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Un laryngoscope avec un manche court serait plus facile à utiliser. On rappelle que le laryngodcope truphatek dispose d'un manche court.

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OBJECTIVE:

To assess the effectiveness of a standard long-handle laryngoscope and a short-handle laryngoscope on ease of possible intubation in football, ice hockey, and soccer players.

DESIGN:

Prospective crossover study.

SETTING:

University Sport Medicine Clinic.

PARTICIPANTS:

Sixty-two university varsity football (62 males), 45 ice hockey (26 males and 19 females), and 39 soccer players (20 males, 19 females).

INTERVENTIONS:

Athletes were assessed for different airway and physical characteristics. Three different physicians then assessed the use of laryngoscopes of different handle sizes in supine athletes who were wearing protective equipment while in-line cervical spine immobilization was maintained.

MAIN OUTCOME MEASURES:

The ease of passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was assessed using both a standard long-handle and a short-handle laryngoscope.

RESULTS:

Use of a short-handle laryngoscope was easier for all physicians in all sports as compared with a standard-sized laryngoscope. Passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was easiest in soccer players and most difficult in football and ice hockey players for both sizes of laryngoscope. Interference from chest or shoulder pads was a common cause for difficulty in passing the laryngoscope blade into the posterior oropharynx for football and ice hockey players.

CONCLUSIONS:

In the rare instances that an endotracheal intubation is to be attempted on an unconscious athlete, a short-handle laryngoscope may provide the best chance for successful intubation.

| Tags : airway, intubation

Vidéolaryngoscopie: Un standard ? Pas si sûr et pas partout !

Videolaryngoscope as a standard intubation device

Xue FS et Al. Br. J. Anaesth. (2015) 115 (1): 137-138

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Un éditorial récent, présentant la vidéolaryngoscopie comme le standard pour toute intubation (1),  dans le BJA a déclenché plusieurs réactions. Nous rapportons là l'une d'elle qui apporte un gros bémol à cette position (ce n'est pas la seule). La vidéolaryngoscopie ( ou plutôt les vidéolaryngoscopes car le choix est grand) doivent certainement trouver leur(s) place(s): . Non pas permettre une intubation facile mais améliorer la sécurité des patients/blessés pris en charge. L'objectif de l'intubation n'est pas de voir le plan glottique mais d'insérer une sonde dans une trachée, ce qui n'est pas la même chose. Dans notre contexte de traumatologie faciale il est fort probable que la vidéolaryngoscopie soit inopérante. Que faire alors ? Ne pas pouvoir s'appuyer sur des pratiques ayant fait leurs preuves ne parait pas actuellement raisonnable même si la maîtrise de ces dernières demande un investissement personnel. On en revient à une chose essentielle qui est l'entraînement à des pratiques qui certes sont peu fréquentes mais qui feront la différence et qui font que l'on peut parler de médicalisation de l'avant.

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The editorial article by Zaouter and colleagues (1) recommending videolaryngoscopy as a new standard of care was of great interest. Videolaryngoscopes are indeed promising intubation devices because they provide an improved laryngeal view.

However, we do not agree with the authors that videolarygnoscopes should replace direct laryngoscopes and be used for all intubations in current practice. The quantitative review and meta-analysis regarding the performance of video- and direct laryngoscopes indicate that in patients with a normal airway, the success rate of intubation with videolarygnoscopes is approximately the same as with direct laryngoscopes, but the intubation time is significantly prolonged with videolaryngoscopes; that is, tracheal intubation in patients with a normal airway can be achieved quickly and in a cost-efficient manner with direct laryngoscopes.

In fact, the most convincing literature to date supports the use of videolaryngoscopes only in unanticipated, difficult, or failed intubations with direct laryngoscopy. The available evidence also shows that videolaryngoscopes are associated with better intubation success and faster intubation time only for inexperienced operators, but they provide no benefit in either of these outcomes with experienced operators. Thus, we argue that videolaryngoscopes are not the best care for all patients and the direct laryngoscope is not an outdated intubation device, especially for providers able to complete substantial training in controlled circumstances, such as experienced anaesthetists, who are often called as airway experts. Furthermore, there are several different types of videolaryngoscopes available, each with a different blade shape, user interface and geometry, and tube insertion strategy. So far, there is inconclusive evidence to indicate which videolaryngoscope design could be more advantageous in various clinical situations. Thus, the open questions remain. Which videolaryngoscope is the most cost-effective device for routine or difficult intubation? Which one is the optimum to become a new standard of care? Given that device-specific proficiency is critical for successful use of any intubation device, if videolaryngoscopes are used as routine intubation devices, do anesthesiologists need to learn and achieve clinical competence for all devices? Perhaps, there might be a need to revise the current airway training programmes because they do not include videolaryngoscopic intubation training in the minimal skill set acquired by a trainee during an airway rotation.7 In addition, most of current difficult airway algorithms are developed as rescue guides in the event of difficult or failed direct laryngoscopy, and these algorithms rely on videolaryngoscopes as rescue tools for difficult or failed direct laryngoscopy.

Although use of videolaryngoscopes is rapidly growing in clinical practice, there is still no evidence-based airway algorithm where tracheal intubation relies mainly on videolaryngoscopy. If videolaryngoscopes are used as the routine first-line intubation devices, one pertinent question is, what should one do in the event of a difficult or failed videolaryngoscopy? It must be emphasized that despite the very good visualization of the glottis, videolaryngoscopy does not give a 100% success rate. In a two-centre study, the GlideScope videolaryngoscope failed once every 33 patients with a difficult airway and once every 16 patients with failed direct laryngoscopy. Thus, if videolaryngoscopes are part of a new airway management protocol in which they are routinely used as first-line intubation devices, there would be a need to reconsider airway management algorithms and adopt a strategy to manage failures.

Finally, Zaouter and colleagues (1) advise integration of videos obtained during videolaryngoscopic intubation into an anaesthesia information management system. To the best of our knowledge, most videolaryngoscopes used in current practice have no such function to transmit moment-by-moment videos into an anaesthesia information management system, and some of them even have no functional design for recording and saving intubation pictures. Perhaps, the manufacturers of videolaryngoscopes should be encouraged to provide such electronic additions to their products in order to integrate imaging of the patient's tracheal intubation into anaesthesia electronic charting. We believe that with further developments and refinements in technology, this may no longer be an issue.

| Tags : airway

20/06/2015

Intubation: L'exemple des paramedic

The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation

Prekker ME et AL. Crit Care Med. 2014 Jun;42(6):1372-8

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En France les seuls infirmiers à intuber sont les IADE. Pourtant dans le reste du monde d'autres catégories de personnels de santé non médecins le pratiquent. Les EMT communément appelés paramedic sont formés et réalisent ce geste en préhopsitalier. Il existe maintenant suffisamment de littérature pour pouvoir dire que cette pratique est valide avec bien sûr la nécessité d'une formation adaptée. C'est que rapporte  ce document qui n'est pas le seul.

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OBJECTIVES:

Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics.

DESIGN:

Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.

SETTING:

Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation).

PATIENTS:

A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523).

ParamedicIntubation.jpg

Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies.

CONCLUSIONS:

Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.

 

| Tags : intubation, airway

Intubation par les paramedic: Affaire de formation et de pratique

Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12 month review of practice

Mc Queen C et Al. Emerg Med J. 2015 Jan;32(1):65-9.

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A l'évidence, cette analyse montre que ce n'est pas une question de statut mais de formation et d'entrainement. Mais il s'agit là d'une autre culture médicale

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INTRODUCTION:

In the West Midlands region of the UK, delivery of pre-hospital care has been remodelled through introduction of a 24 h Medical Emergency Response Incident Team (MERIT). Teams including physicians and critical care paramedics (CCP) are deployed to incidents on land-based and helicopter-based platforms. Clinical practice, including delivery of rapid sequence induction of anaesthesia (RSI), is underpinned by standard operating procedures (SOP). This study describes the first 12 months experience of prehospital RSI in the MERIT scheme in the West Midlands.

METHODS:

Retrospective review of the MERIT clinical database for the 12 months following the launch of the scheme. Data was collected relating to the number of RSIs performed; indication for RSI; number of intubation attempts; grade of view on laryngoscopy and the base speciality/grade of the operator performing intubation.

RESULTS:

MERIT teams were activated 1619 times, attending scene in 1029 cases. RSI was performed 142 times (13.80% of scene attendances). There was one recorded case of failure to intubate requiring insertion of a supraglottic airway device (0.70%). In over a third of RSI cases, CCPs performed laryngoscopy and intubation (n=53, 37.32%). Proficiency of obtaining Grade I view at laryngoscopy was similar for physicians (74.70%) and CCPs (77.36%). Intubation was successful at the first attempt in over 90% of cases.

CONCLUSIONS:

This study demonstrates that operation within a system that provides high levels of exposure, underpinned by comprehensive and robust training and governance frameworks, promotes levels of performance in successful prehospital RSI regardless of base speciality or profession.

 

| Tags : intubation, airway

19/06/2015

Vidéolaryngoscopie: Oui au moins dans les hélico !

Evolution of Pararescue Medicine During Operation Enduring Freedom

Rush S et All. Mil Med. 2015 Mar;180(3 Suppl):68-73

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Les conditions d'intubations lors d'un transport hélico peuvent nécessiter une intubation face à face. Bien que discuté, dans de telles conditions l'apport d'un vidéolaryngoscope est utile. Les pararescue US font la même analyse.

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IntubFaceFace.jpg

This article highlights recent advances made in U.S. Air Force Pararescue Medical Operations in relation to tactical evacuation procedures. Most of these changes have been adopted and adapted from civilian medicine practice, and some have come from shared experiences with partner nations. Patient assessment includes a more comprehensive evaluation for hemorrhage and indications for hemorrhagic control. Ketamine has replaced morphine and fentanyl as the primary sedative used during rapid sequence intubation and procedural sedation. There has been an increasing use of the bougie to clear an airway or nasal cavity that becomes packed with debris. Video laryngoscopy provides advantages over direct laryngoscopy, especially in situations where there are environmental constraints such as the back of a Pave Hawk helicopter. Intraosseous access has become popular to treat and control hemorrhagic shock when peripheral intravenous access is impractical or impossible. Revisions to patient treatment cards have improved the efficacy and compliance of documentation and have made patient handoff more efficient. These improvements have only been possible because of the concerted efforts of U.S. Air Force and partner platforms operating in Afghanistan.

| Tags : intubation, airway

18/06/2015

Intubation difficile: La vision canadienne actualisée

Prise en charge des voies aériennes – 1re partie – Recommandations lorsque des difficultés sont constatées chez le patient inconscient/anesthésie

Can J Anesth/J Can Anesth (2013) 60:1089–1118

Un document à lire dans le détail car insistant beaucoup sur la notion de facteur humain et se positionnant volontairement en retrait sur les aspects matériels mis en avant ces dernières années;

IntubDiffCANADA Algo 1.JPG

Prise en charge des voies aériennes – 2e partie – Recommandations lorsque des difficultés sont prévues

Can J Anesth/J Can Anesth (2013) 60:1119–1138

 

IntubDiffCANADA Algo 2.JPG

| Tags : intubation, airway