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31/10/2014

HES: Du côté des belges

Hydroxyethyl Starches in the Perioperative Period. A review on the efficacy and safety of starch solutions

Ghuselings I et All. Acta Anaesth. Belg., 2014, 65, 9-22

Several randomized controlled trials have raised alarming concerns about the safety of hydroxyethyl starches (HES) for the hemodynamic stabilization of critically ill patients. It has been repeatedly demonstrated that the use of HES in patients treated in an intensive care unit was associated with an increased occurrence of serious adverse events, including a higher incidence of renal injury or failure, a higher need for renal replacement therapy (RRT), and (in one study) increased mortality. HES solutions are also widely used in the perioperative period, although high-level evidence on both the efficacy and safety of HES in patients undergoing surgery is sparse. It is unknown to which extent the concerning findings in critically ill patients can be extrapolated to the perioperative setting, where a variety of distinct patient populations is encountered. However, caution and an increased awareness for possible adverse effects of HES solutions in the perioperative setting are warranted. In 2013, the European Medicines Agency (EMA) concluded that the benefits of HES solutions no longer outweigh their risks, and therefore recommended that the marketing authorizations for these medicines be suspended (1). Upon request of some of the marketingauthorization holders (MAH), the EMA re-analyzed its recommendation. After a thorough review of the available data, the Pharmacovigilance Risk Assessment Committee (PRAC) concluded, on November 11th, that the increased risk of mortality and RRT or renal failure associated with the use of hydroxyethyl starch containing medicinal products outweighs their limited clinical benefits in the approved indications, and in any patient population. In June 2013, the U.S. Food and Drug Administration also communicated a serious warning with respect to the use of HES (2). The present (non-systematic) review summarizes the evidence upon which these remarkable recommendations are based. Moreover, current guidelines on the use of HES are quoted.

HES.jpg

Garrot: Pas de jeu avant de serrer

No slackers in tourniquet use to stop bleeding

Polston RW et Al.  J Spec Oper Med. 2013 Summer;13(2):12-9.

 

La performance d'un garrot tient pour beaucoup à la manière dont il va être posé. Le garrot en dotation comporte un dispositif de serrage de type tourniquet. L'efficacité de ce dispositif est en grande partie liée à l'absence de jeu au niveau de la sangle du garrot avant le serrage. Il est fondamental de positionner le garrot à la racine du membre, de le mettre en tension manuellement en tirant sur la sangle de façon à effectuer un premier serrage du garrot  et ensuite de renforcer ce serrage par la barre du tourniquet. On rappelle qu'en principe l'efficacité est obtenue à partir de 3 tours. (la fiche technique). Le travail présenté ci après est éloquent sur l'intérêt de prohiber tout jeu avec de tourner la barre de torsion.

 

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Background: Tourniquets on casualties in war have been loose in 4%?9% of uses, and such slack risks death from uncontrolled bleeding. A tourniquet evidence gap persists if there is a mechanical slack?performance association.

Objective: The purpose of the present study was to determine the results of tourniquet use with slack in the strap versus no slack before windlass turning, in order to develop best practices. Methods: The authors used a tourniquet manikin 254 times to measure tourniquet effectiveness, windlass turns, time to stop bleeding, and blood volume lost at 5 degrees of strap slack (0mm, 25mm, 50mm, 100mm, and 200mm maximum).

Results: When comparing no slack (0mm) to slack (any positive amount), there were increases with slack in windlass turns (p < .0001, 3-fold), time to stop bleeding (p < .0001, 2-fold), and blood volume lost (p < .0001, 2-fold). When comparing no slack to 200mm slack, the median results showed an increase in slack for windlass turns (p < .0001), time to stop bleeding (p < .0001), and blood volume lost (p < .0001).

Slack.jpg

 

Conclusions: Any slack presence in the strap impaired tourniquet performance. More slack had worse results. Trainers can now instruct tourniquet users with concrete guidance.

| Tags : garrot, tourniquet

Garrot: Comment positionner la boucle ?

Emergency tourniquet effectiveness in four positions on the proximal thigh.

Kragh JF et Al. J Spec Oper Med. 2014 Spring;14(1):26-9.

 

La procédure du sauvetage au combat précise que le garrot doit être posé à la racine du membre. Elle ne précise cependant pas comment le dispositif de serrage doit être placé: en avant sur le côté en arrière du membre. Ce travail tente de répondre à cette question.

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Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions: medial, lateral, anterior, and posterior? to inform tourniquet instructors and develop best tourniquet practices.

Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions.

Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under thetourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations betweentourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh

 

| Tags : tourniquet, garrot

Garrot jonctionnel: CROC et SAM ?

Testing of junctional tourniquets by military medics to control simulated groin hemorrhage.

Kragh JF et Al. J Spec Oper Med. 2014 Fall;14(3):58-63.

 

Ce qui est certain, c'est ce qui est écrit sur cette image

Jnctional.jpg

Difficile d'avoir une idée précise sur les performances relatives des matériels proposés par les industriels. Ce qui suit éclaire un peu.

BACKGROUND:

Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care.

METHODS:

Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems.com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?"

RESULTS:

All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant.

CONCLUSION:

The SJT and the CRoC were equally effective and fast and were preferred by the participants

| Tags : jonctionnel

30/10/2014

Plaquettes synthétiques: Possible ? Mais oui

Tuning Ligand Density on Intravenous Hemostatic Nanoparticles Dramatically Increases Survival Following Blunt Trauma

Proc Natl Acad Sci U S A. 2014 Jul 15;111 (28) 10293-10298

Des plaquettes synthétiques pour arrêter le saignement ? Certains l'ont fait grâce à la technologie des nanoparticules (1, 2). Un espoir qui reste à confirmer.

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Explosions account for 79% of combat-related injuries, leading to multiorgan hemorrhage and uncontrolled bleeding. Uncontrolled bleeding is the leading cause of death in battlefield traumas as well as in civilian life. We need to stop the bleeding quickly to save lives, but, shockingly, there are no treatments to stop internal bleeding. A therapy that halts bleeding in a site-specific manner and is safe, stable at room temperature, and easily administered is critical for the advancement of trauma care. To address this need, we have developed hemostatic nanoparticles that are administered intravenously. When tested in a model of blast trauma with multiorgan hemorrhaging, i.v. administration of the hemostatic nanoparticles led to a significant improvement in survival over the short term (1 h postblast). No complications from this treatment were apparent out to 3 wk. This work demonstrates that these particles have the potential to save lives and fundamentally change trauma care.

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| Tags : hémorragie

The Blue protocol

Lung ultrasound in the critically ill

Lichtenstein D. Annals of Intensive Care 2014, 4:1

 

Une approche systématisée de l'échographie pulmonaire simpllfie et fiabilise cet examen. C'est ce qu'explique cette publication  

BlueProtocol.jpg 

Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating lung consolidation, the B-line, and lung rockets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothorax, and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using CT as the “gold standard” with sensitivity and specificity ranging from 90% to 100%, allowing ultrasound to be considered as a reasonable bedside “gold standard” in the critically ill. The BLUE-protocol is a fast protocol (<3 minutes), which allows diagnosis of acute respiratory failure. It includes a venous analysis done in appropriate cases. Pulmonary edema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax yield specific profiles. Pulmonary edema, e.g., yields anterior lung rockets associated with lung sliding, making the “B-profile.” The FALLS-protocol adapts the BLUE-protocol to acute circulatory failure. It makes sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography (right ventricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical volemia: the apparition of B-lines, schematically, is considered as the endpoint for fluid therapy. Other aims of lung ultrasound are decreasing medical irradiation: the LUCIFLR program (most CTs in ARDS or trauma can be postponed), a use in traumatology, intensive care unit, neonates (the signs are the same than in adults), many disciplines (pulmonology, cardiology…), austere countries, and a help in any procedure (thoracentesis). A 1992, cost-effective gray-scale unit, without Doppler, and a microconvex probe are efficient. Lung ultrasound is a holistic discipline for many reasons (e.g., one probe, perfect for the lung, is able to scan the whole-body). Its integration can provide a new definition of priorities. The BLUE-protocol and FALLS-protocol allow simplification of expert echocardiography, a clear advantage when correct cardiac windows are missing.

 

27/10/2014

Perfuser + vite: Pas n'importe comment !

Novel rapid infusion device for patients in emergency situations

Kapoor DJ et Al. Scand J Trauma Resusc Emerg Med. 2011 Jun 10;19:35

Il peut être nécessaire d'accélérer le débit d'une perfusion. Pour cela il peut être fait appel à une manchette à pression, une tubulure de type 'blood pump", un système "robinet 3 voies ", plus rarement un système à compression par lame voire une pompe électrique.

Le document présenté fait appel à l'injection d'air dans le corps du soluté utilisé. La sécurité de cette manière de faire interpelle quelque peu. En effet les auteurs estiment que le filtre 15µ présent dans la tubulure a un effet barrière anti air suffisant pour éviter tout risque d'embolie gazeuse. 

Rapidnfusion.jpgCe type de pratique est associé à une prise de risque du fait du concept même de la méthode, des conditions d'hygiène non respectées et des conditions de surveillance non optimales en conditions extrême.

 

23/10/2014

Pansements hémostatiques: Actualisation 2014

Review of New Topical Hemostatic Dressings for Combat Casualty Care

Benett BL et Al Mil Med. 2014 May;179(5):497-514

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third- generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

14/10/2014

Pansements hémostatiques: Actualisation 2014 TCCC

Management of External Hemorrhage  in Tactical Combat Casualty Care: 

Chitosan-Based Hemostatic Gauze Dressings

TCCC Guidelines – Change 13-05

Le point sur l'emploi des pansements hémostatiques. Pas de grands changements le Quikclot Combat Gauze reste la référence mais le Chitosan et le Celox gauze sont considérés comme équivalents.

Cliquer sur le lien pour accéder à l'argumentaire

TCCC%20Bennett%20Hemostatic%20Drsngs%20TCCC%20Change%20JS...

TCCC Mise à jour 06/2014

Tactical Combat Casualty Care Guidelines

2 June 2014

(Includes all changes through #14-01)

 

These recommendations are intended to be guidelines only and are not a substitute for clinical judgment.

  

Basic Management Plan for Care Under Fire

 

  1. Return fire and take cover.

  2. Direct or expect casualty to remain engaged as a combatant if appropriate.

  3. Direct casualty to move to cover and apply self-aid if able.

  4. Try to keep the casualty from sustaining additional wounds.

  5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.

  6. Airway management is generally best deferred until the Tactical Field Care phase.

  7. Stop life-threatening external hemorrhage if tactically feasible:

  • Direct casualty to control hemorrhage by self-aid if able.

  • Use a CoTCCC-recommended tourniquet for hemorrhage that is anatomically amenable to tourniquet application.

  • Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover.

Basic Management Plan for Tactical Field Care

 

  1. Casualties with an altered mental status should be disarmed immediately.

  2. Airway Management

    1. Unconscious casualty without airway obstruction:

      • Chin lift or jaw thrust maneuver

      • Nasopharyngeal airway

      • Place casualty in the recovery position

    2. Casualty with airway obstruction or impending airway obstruction:

      • Chin lift or jaw thrust maneuver

      • Nasopharyngeal airway

      • Allow casualty to assume any position that best protects the airway, to include sitting up.

      • Place unconscious casualty in the recovery position.

      • If previous measures unsuccessful:

      • Surgical cricothyroidotomy (with lidocaine if conscious)

  1. Breathing

a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).

  1. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

  2. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.

4. Bleeding

a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauzemay also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury (TBI). If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, replace tourniquet over uniform with another applied directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.

d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side-by-side and proximal to the first, to eliminate the distal pulse.

e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

5. Intravenous (IV) Access

a. Start an 18-gauge IV or saline lock if indicated.

b. If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route.

 

6. Tranexamic Acid (TXA)

a. If a casualty is anticipated to need significant blood transfusion (for example; presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):

1. Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringer’s as soon as possible but NOT later than 3 hours after injury.

2. Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

 

7. Fluid Resuscitation

a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

1. If not in shock:

- No IV fluids are immediately necessary.

- Fluids by mouth are permissible if the casualty is conscious and can swallow.

2. If in shock and blood products are available under an approved command or theater blood product administration protocol:

- Resuscitate with whole blood*, or, if not available

- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available

- Plasma and RBCs in 1:1 ratio, or, if not available;

- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone.

- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.

3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:

- Resuscitate with Hextend, or if not available;

- Lactated Ringers or Plasma-Lyte A.

- Reassess the casualty after each 500 mL IV bolus.

- Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.

- Discontinue fluid administration when one or more of the above end points has been achieved.

4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.

5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

 

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

8. Prevention of Hypothermia

a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.

b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.

c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.

e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

f. Warm fluids are preferred if IV fluids are required.

9. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:

1. Perform a rapid field test of visual acuity.

2. Cover the eye with a rigid eye shield (NOT a pressure patch.)

3. Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

10. Monitoring

Pulse oximetry should be available as an adjunct to clinical monitoring. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

 

11. Inspect and dress known wounds.

 

12. Check for additional wounds.

 

13. Analgesia on the battlefield should generally be achieved using one of three options:

Option 1

Mild to Moderate Pain

Casualty is still able to fight

- TCCC Combat pill pack:

- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours

- Meloxicam - 15 mg PO once a day

Option 2

Moderate to Severe Pain

Casualty IS NOT in shock or respiratory distress AND

Casualty IS NOT at significant risk of developing either condition

- Oral transmucosal fentanyl citrate (OTFC) 800 ug

- Place lozenge between the cheek and the gum

- Do not chew the lozenge

Option 3

Moderate to Severe Pain

Casualty IS in hemorrhagic shock or respiratory distress OR

Casualty IS at significant risk of developing either condition

- Ketamine 50 mg IM or IN

Or

- Ketamine 20 mg slow IV or IO

 

* Repeat doses q30min prn for IM or IN

* Repeat doses q20min prn for IV or IO

* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

 

* Analgesia notes

a. Casualties may need to be disarmed after being given OTFC or ketamine.

b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely

d. Directions for administering OTFC:

- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.

- Reassess in 15 minutes

- Add second lozenge, in other cheek, as necessary to control severe pain

- Monitor for respiratory depression

e. IV Morphine is an alternative to OTFC if IV access has been obtained

- 5 mg IV/IO

- Reassess in 10 minutes.

- Repeat dose every 10 minutes as necessary to control severe pain.

- Monitor for respiratory depression

f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.

g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.

j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.

l. Reassess – reassess – reassess!

14. Splint fractures and recheck pulses.

15. Antibiotics: recommended for all open combat wounds

a. If able to take PO:

1. Moxifloxacin, 400 mg PO one a day

b. If unable to take PO (shock, unconsciousness):

1. Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours

or

2. Ertapenem, 1 g IV/IM once a day

16. Burns

a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

d. Fluid resuscitation (USAISR Rule of Ten)

  1. If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.

  2. Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.

  3. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

  4. If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.

e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.

f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.

g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

17. Communicate with the casualty if possible.

a. Encourage; reassure

b. Explain care

18. Cardiopulmonary Resuscitation (CPR)

Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in Section 3 above.

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.

 

Basic Management Plan for Tactical Evacuation Care

Note: The term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02.

 

1. Airway Management

a. Unconscious casualty without airway obstruction:

      1. Chin lift or jaw thrust maneuver

      2. Nasopharyngeal airway

      3. Place casualty in the recovery position

b. Casualty with airway obstruction or impending airway obstruction:

        1. Chin lift or jaw thrust maneuver

        2. Nasopharyngeal airway

        3. Allow casualty to assume any position that best protects the airway, to include sitting up.

        4. Place unconscious casualty in the recovery position.

        5. If above measures unsuccessful:

  • Supraglottic airway or

  • Endotracheal intubation or

  • Surgical cricothyroidotomy (with lidocaine if conscious).

c. Spinal immobilization is not necessary for casualties with penetrating trauma.

 

2. Breathing

a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).

b. Consider chest tube insertion if no improvement and/or long transport is anticipated.

c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties:

- Low oxygen saturation by pulse oximetry

- Injuries associated with impaired oxygenation

- Unconscious casualty

- Casualty with TBI (maintain oxygen saturation > 90%)

- Casualty in shock

- Casualty at altitude

d. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

3. Bleeding

a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if anticipated evacuation time is longer than two hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no TBI.) If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, replace tourniquet over uniform with another applied directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.

d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side-by-side and proximal to the first, to eliminate the distal pulse.

e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

4. Intravenous (IV) Access

a. Reassess need for IV access.

1. If indicated, start an 18-gauge IV or saline lock

2. If resuscitation is required and IV access is not obtainable, use intraosseous (IO) route.

5. Tranexamic Acid (TXA)

a. If a casualty is anticipated to need significant blood transfusion (for example; presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):

1. Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.

2. Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

6. Traumatic Brain Injury

a. Casualties with moderate/severe TBI should be monitored for:

1. Decreases in level of consciousness

2. Pupillary dilation

3. SBP should be >90 mmHg

4. O2 sat > 90

5. Hypothermia

6. PCO2 (If capnography is available, maintain between 35-40 mmHg)

7. Penetrating head trauma (if present, administer antibiotics)

8. Assume a spinal (neck) injury until cleared.

b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure*:

1. Administer 250 cc of 3 or 5% hypertonic saline bolus.

2. Elevate the casualty’s head 30 degrees.

3. Hyperventilate the casualty:

  • Respiratory rate 20.

  • Capnography should be used to maintain the end-tidal CO2 between 30-35.

  • The highest oxygen concentration (FIO2) possible should be used for hyperventilation.

 

* Notes:

Do not hyperventilate unless signs of impending herniation are present.

Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.

7. Fluid Resuscitation

a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

1. If not in shock:

  • No IV fluids are immediately necessary.

  • Fluids by mouth are permissible if the casualty is conscious and can swallow.

2. If in shock and blood products are available under an approved command or theater blood product administration protocol:

  • Resuscitate with whole blood*, or, if not available

  • Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available;

  • Plasma and RBCs in 1:1 ratio, or, if not available;

  • Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone.

  • Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.

3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:

  • Resuscitate with Hextend, or if not available;

  • Lactated Ringers or Plasma-Lyte A;

  • Reassess the casualty after each 500 mL IV bolus;

  • Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.

  • Discontinue fluid administration when one or more of the above end points has been achieved.

4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.

5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

 

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

8. Prevention of Hypothermia

a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.

b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.

c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.

e. If the items mentioned above are not available, use poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

f. Use a portable fluid warmer capable of warming all IV fluids including blood products.

g. Protect the casualty from wind if doors must be kept open.

9. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:

1. Perform a rapid field test of visual acuity.

2. Cover the eye with a rigid eye shield (NOT a pressure patch).

3. Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

 

10. Monitoring

Institute pulse oximetry and other electronic monitoring of vital signs, if indicated. All individuals with moderate/severe TBI should be monitored with pulse oximetry.

 

11. Inspect and dress known wounds if not already done.

 

12. Check for additional wounds.

 

13. Analgesia on the battlefield should generally be achieved using one of three options:

Option 1

Mild to Moderate Pain

Casualty is still able to fight

- TCCC Combat pill pack:

- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours

- Meloxicam - 15 mg PO once a day

Option 2

Moderate to Severe Pain

Casualty IS NOT in shock or respiratory distress AND

Casualty IS NOT at significant risk of developing either condition

- Oral transmucosal fentanyl citrate (OTFC) 800 ug

- Place lozenge between the cheek and the gum

- Do not chew the lozenge

Option 3

Moderate to Severe Pain

Casualty IS in hemorrhagic shock or respiratory distress OR

Casualty IS at significant risk of developing either condition

- Ketamine 50 mg IM or IN

Or

- Ketamine 20 mg slow IV or IO

 

* Repeat doses q30min prn for IM or IN

* Repeat doses q20min prn for IV or IO

* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

 

* Analgesia notes

a. Casualties may need to be disarmed after being given OTFC or ketamine.

b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely

d. Directions for administering OTFC:

- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.

- Reassess in 15 minutes

- Add second lozenge, in other cheek, as necessary to control severe pain

- Monitor for respiratory depression

e. IV Morphine is an alternative to OTFC if IV access has been obtained

- 5 mg IV/IO

- Reassess in 10 minutes.

- Repeat dose every 10 minutes as necessary to control severe pain.

- Monitor for respiratory depression

f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.

g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.

j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.

l. Reassess – reassess – reassess!

14. Reassess fractures and recheck pulses.

 

15. Antibiotics: recommended for all open combat wounds

a. If able to take PO:

1. Moxifloxacin, 400 mg PO one a day

b. If unable to take PO (shock, unconsciousness):

1. Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours

or

2. Ertapenem, 1 g IV/IM once a day

16. Burns

a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

d. Fluid resuscitation (USAISR Rule of Ten)

  1. If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.

  2. Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.

  3. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

  4. If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.

e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.

f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.

g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid warming in this phase.

17. The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding. Application and extended use must be carefully monitored. The PASG is contraindicated for casualties with thoracic or brain injuries.

18. CPR in TACEVAC Care

a. Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in Section 2 above.

b. CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties.

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.

 

| Tags : tccc

11/10/2014

Suis je bien dans la trachée ?

Comment vérifier la position intratrachéale d'une sonde d'intubation ? 

Le débat n'est pas nouveau (1). L'intérêt de l'intubation en condition de combat est d'ouvrir les voies aériennes, de prévenir le risque d'inhalation et de permettre l'application d'une ventilation adéquate. Son indication doit être bien mesurée car elle va ajouter une dimension de complexité pour un transport préhospitalier qui n'a rien à voir avec ce qui est rencontré en métropole.

Alors quelques réflexions ne sont pas inutiles car il faut éviter tant l'intubation oesophagienne que l'intubation sélective.

1. La visualisation de la sonde entre les cordes vocales est la base que ce soit au moment de la laryngoscopie initiale ou d'un contrôle après MAIS ce n'est pas suffisant, et pas forcément toujours possible.

2. La recherche d'une auscultation symétrique des 2 champs pulmonaires et d'un silence auscultatoire épigastrique doivent être fait MAIS ce n'est pas suffisant, et parfois difficile à obtenir.

3. L'expansion thoracique symétrique et la constatation de buée sur la sonde sont observées MAIS ce n'est pas suffisant.

4. Le recours à la mesure d'une SaO2 MAIS n'est pas du tout fait pour cela.

5. Utiliser une seringue ou un bulbe spécifique MAIS n'offre pas de certitude et c'est une techniQue peu diffusée en France

6. La CERTITUDE de l'intubation est donnée par la constatation de CO2 dans le gaz expiré à condition que soient respectés des critères quantitatifs et qualitatifs. Notamment les capnogrammes doivent être visualisés sur au moins 6 cycles ventilatoires durant lesquels l’absence de décroissance du signal confirme la bonne position de la sonde. (accéder à la conférence de consensus de la SFAR). Cette analyse qualitative est importante car le CO2 observé peut provenir d'air gastrique insufflé lors de ventilation manuelle voire d'anti-acides gastriques.

Mais dans notre contexte d'emploi la capnographie, telle que l'on la connait au bloc opératoire ou en SAUV, n'est pas le plus souvent disponible. Vous disposez de capteurs chimiques qui ne donnent qu'une estimation de la capnométrie. Certains disposent d'un capnomètre portable mais qui ne donne pas d'informations qualitatives. Enfin il existe des détecteurs oesophagiens dont la performance est bonne (2), sous réserve de conditions de stockage et d'emploi conforme notamment de température ambiante,  mais qui ne permettent pas une surveillance continue et surtout si ils sont fiables pour confirmer la position intra-trachéale, ils le sont beaucoup moins pour la position intra-oeosophagienne.

7. Du nouveau arrive avec l'emploi de l'échographie pour valider la position intra-trachéale de la sonde d'intubation:

- soit par échographie cervicale (3, 4),

Airway Echo.jpg

 Kerforne T et al. Br. J. Anaesth. 2013;111:510-511

 - soit par constatation de mouvements pleuraux bilatéraux (5)

Echo Airway 2.jpg

- ou encore d'une mobilité diaphragmatique lors de la ventilation (6)

EchoAirway 3.jpg

Int J Crit Illn Inj Sci. 2013 Apr;3(2):113-7 

En contexte Militaire et en l'absence de capnographe, il faut, avant fixation de la sonde de vérification, dans le cadre  la réalisation de mesures primaires de vérification de la bonne position de la sonde d'intubation  ASSOCIER l'observation directe de la sonde franchissant les cordes vocales, l'expansion symétrique du thorax lors de la ventilation au ballon, la présence de buée dans la sonde, l'auscultation symétrique des deux champs pulmonaires et la présence de CO2 expiré sur le détecteur chimique. L'apport de l'échographie pourrait être d'être l'alternative à la radiographie pulmonaire pour la vérification secondaire de la bonne position de la sonde d'intubation.

Un débat qui porte sur la meilleure performance comparée à la capnographie et l'auscultation du repérage échographique est même déjà ouvert (7, 8, 9).

 

| Tags : airway

06/10/2014

Laryngoscopie directe: Toujours la référence en 1ère intention

Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: a randomized control trial.

Trimmel H et all. Crit Care Med 2011 Mar;39(3):489-93

__________________________________________

Une étude un peu ancienne mais qui a depuis été confirmée par d'autres (1, 2)  et qui met bien en avant l'importance d'un apprentissage renforcé de la gestion des voies aériennes. Une méta-analyse plus récente le confirme (3).

__________________________________________

OBJECTIVES

The optical Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) has been shown to have advantages when compared with direct laryngoscopy in difficult airway patients. Furthermore, it has been suggested that it is easy to use and handle even for inexperienced advanced life support providers. As such, we sought to assess whether the Airtraq may be a reliable alternative to conventional intubation when used in the prehospital setting.

DESIGN, SETTING, AND PATIENTS:

Prospective, randomized control trial in emergency patients requiring endotracheal intubation provided by anesthesiologists or emergency physicians responding with an emergency medical service helicopter or ground unit associated with the Department of Anesthesiology, General Hospital, Wiener Neustadt, Austria.

MEASUREMENTS AND MAIN RESULTS:

During the 18-month study period, 212 patients were enrolled. When the Airtraq was used as first-line airway device (n=106) vs. direct laryngoscopy (n=106), success rate was 47% vs. 99%, respectively (p<.001). Reasons for failed Airtraq intubation were related to the fiber-optic characteristic of this device (i.e., impaired sight due to blood and vomitus, n=11) or to assumed handling problems (i.e., cuff damage, tube misplacement, or inappropriate visualization of the glottis, n=24). In 54 of 56 patients where Airtraq intubation failed, direct laryngoscopy was successful on the first attempt; in the remaining two and in one additional case of failed direct laryngoscopy, the airway was finally secured employing the Fastrach laryngeal mask. There was no correlation between success rates and body mass index, age, indication for airway management, emergency medical service unit, or experience of the physicians.

CONCLUSIONS: 

Based on these results, the use of the Airtraq laryngoscope as a primary airway device cannot be recommended in the prehospital setting without significant clinical experience obtained in the operation room. We conclude that the clinical learning process of the Airtraq laryngoscope is much longer than reported in the anesthesia literature.

| Tags : airway