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18/06/2015

Reco US Intubation difficile

 Guidelines US Difficult Airway.jpg

| Tags : intubation, airway

06/06/2015

La mâchoire en avant: Mieux pour intuber !

Mandibular Advancement Improves the Laryngeal View during Direct Laryngoscopy Performed by Inexperienced Physicians

Tamura M et Al. Anesthesiology 2004; 100:598–601

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Améliorer la vue laryngée pet se faire avec des moyens simples comme la manoeuvre BURP. C'est encore mieux si on associe la protusion mandibulaire. 

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Background: When oral or nasal fiberoptic laryngoscopy is attempted, mandibular advancement has been reported to improve the laryngeal view. The authors hypothesized that mandibular advancement may also improve the laryngeal view during direct laryngoscopy.

Methods: Forty patients undergoing elective surgery under general anesthesia were included in this study. After establishment of an adequate level of anesthesia and muscle relaxation, direct laryngoscopy was performed by inexperienced physicians. Four different maneuvers—simple direct laryngoscopy without any assistance (C), simple direct laryngoscopy with mandibular advancement (M), simple direct laryngoscopy with the BURP maneuver (backward, upward, rightward pressure maneuver of the larynx; B), and simple direct laryngoscopy with both mandibular advancement and the BURP maneuver (BM)—were attempted in each subject, and the laryngeal aperture was videotaped with each procedure. An instructor in anesthesiology who was blinded to the procedure evaluated the visualization by reviewing videotape off-line, using the Cormack-Lehane classification system (grades I–IV) and a rating score within each subject (1  best view; 4  poorest view). The Friedman test followed by the Student-Newman-Keuls test was performed for statistical comparison. P < 0.05 was considered significant.

Results: The laryngeal view was improved with M and B when compared with C (P < 0.05 by both rating and Cormack-Lehane evaluation). BM was the most effective method to visualize the laryngeal aperture (P < 0.05, vs. B and M by rating evaluation), whereas B and M were the second and the third most effective methods, respectively. No statistical difference was observed between B and M with the Cormack-Lehane classification.

intubation,airway

Conclusion: Mandibular advancement improves the laryngeal view during direct laryngoscopy performed by inexperienced physicians. 

 

| Tags : intubation, airway

07/05/2015

CICO: Stratégies et équipement

Equipment and strategies for emergency tracheal access in the adult patient

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

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Un document qui passe en revue les équipements à mettre en oeuvre lors de sutuation de CICO (Can't intubate can't oxygneate)

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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

31/03/2015

Intubation: Le médecin ou L'infirmier ? En fait il faut être bien formé

Role Allocation and Team Dynamics during Pre-Hospital Rapid Sequence Induction of Anaesthesia by a Physician-Critical Care Paramedic Team in the United Kingdom: A 12 Months Review of Practice

Crombie et al., J Anesth Clin Res 2015, 6:2

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La procédure du sauvetage au combat prévoit que les IDE puissent être amenés à intuber un blessé au combat, y compris si un médecin n'est pas présent.  Le travail proposé montre que cela est parfaitement possible grâce à une formation adaptée.

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Background: Critical care paramedics working alongside physicians in the West Midlands MERIT scheme Medical Emergency Response Incident Team (MERIT) have been shown to demonstrate high levels of proficiency in laryngoscopy during Rapid Sequence Induction of anaesthesia (RSI). The MERIT SOP does not stipulate the team member who should be allocated the role of laryngoscopy during RSI. The aim of this study is to analyse and identify factors that influence role allocation in pre-hospital RSI performed by MERIT scheme personnel in the West Midlands.

Methods: We conducted a retrospective review from 12 months of our mission database for patients who had undergone pre-hospital RSI performed by MERIT. Data collected included the indication for RSI, the number of intubation attempts (including documented failures to intubate), documentation of predicted difficulty in intubation and the degree of airway soiling prior to RSI. The clinical role of the operator performing laryngoscopy was recorded for each attempt.

Results: 113 cases or pre-hospital RSI were identified. Critical care paramedics successfully intubated 49/58 (84.48%) cases in which they were allocated the first attempt at laryngoscopy. Success at first attempt lower for physicians (76.92%) but greater proportions of such cases involved patients at the extremes of age and heavy airway soiling with a wider range of indications.

Conclusions: As part of a multidisciplinary team working alongside physicians, Critical Care Paramedics successfully intubate the majority of patients at the first attempt in carefully selected groups. Further research to investigate other factors at scene that influence role allocation and team dynamics in pre-hospital RSI is required

| Tags : airway

17/03/2015

Sellick: Mieux vaut être formé pour faire.

Cricoid pressure training using simulation: a systematic review and meta-analysis

Johnson RL et AL. Br J Anaesth. 2013 Sep;111(3):338-46

Le recours à la manoeuvre de Sellick est très controversé (1). Quelle que soit son efficacité réelle, une chose est certaine c'est qu'elle doit être correctement réalisée (2). L'application d'une pression cricoïdienne de 20N dès le début de l'induction pour atteindre 40N à la perte de conscience est requise (3). Le travail présenté met en évidence l'importance de la formation pour la maîtrrise de ce geste.

CricoTraining.jpg

Clic sur l'image pour accéder au document

 

| Tags : airway

06/03/2015

Intubation préhospitalière: Être conscient du temps qui passe

Implementing new advanced airway management standards in the Hungarian physician staffed Helicopter Emergency Medical Service.

Soti A; et Al Scand J Trauma Resusc Emerg Med. 2015 Jan 9;23(1):3.

Parmi tous les risques qui peuvent être rencontrés en médecine d'urgence, il y a l'effet tunnel. Vouloir à tout prix réussir un geste et oublier pourquoi. L'article présenté introduit insiste sur l'importance d'appliquer un algorithme et d'en respecter touts les phases. Par exemple la notion du temps  lors de la réalisation de la première laryngoscopie est importante. 

rsi.jpg 

clic sur l'image pour accéder au document

| Tags : airway

18/01/2015

Airway aux urgences en Corée: Avec quoi ?

Assessment of Emergency Airway Management Techniques in Korea Using an Online Registration System: A Multicenter Study.

Press GM et AL. J Emerg Med. 2014 Dec;47(6):638-45

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L'essor de la vidéo-laryngoscopie est incontournable. Ceci  ne doit cependant pas faire oublier que cet outil ne remplace pas (encore) la pratique régulière de la laryngoscopie directe notamment dans le cadre de la prise en charge des traumatisés. C'est du moins ce que laisse entendre ce document coréen qui pointe  néanmoins l'apport de cette dernière dans les conditions d'intubation diffiicle.

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BACKGROUND:

 

The investigators developed a Web-based online registration system to identify the current status of trauma airway management.

OBJECTIVES:

The purpose of the study was to identify first-pass success (FPS) rate of the intubation methods and devices that are currently used, as well as the factors that affect FPS in trauma patients.

METHODS:

This study was designed as a prospective, observational multi-center study. We obtained clinical data of intubated trauma patients in 13 academic emergency departments in Korea. After performing an intubation, each patient's data were entered into a Web-based registry. Logistic regression analyses were conducted to identify the factors that affect FPS.

RESULTS:

The FPS rate was 80.6% in all trauma patients. The curved-blade laryngoscope was the most commonly used instrument, and was applied to 1395 patients (76.2%) during first attempt. Video laryngoscopy was applied to 341 patients (18.6%). In the multivariate logistic regression analysis, factors that affected FPS in difficult airway trauma patients were emergency physicians, senior physicians, and video laryngoscopy (odds ratio 2.42, 95% confidence interval 1.04-5.65; 1.80, 1.16-2.79; and 2.16, 1.39-3.33, respectively).

VideoLarynKOREA.jpg

CONCLUSIONS:

Emergency physicians in Korea are prepared for trauma patient airway management. The backup by experienced senior physicians, and preparation and training for video laryngoscope could assist FPS for trauma patients.

| Tags : airway

07/01/2015

Gonflez le ballonnet à l'eau et échographiez le au niveau de la fourchette sternale !

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children

Tessaro MO et Al. Resuscitation. 2014 Sep 17. pii: S0300-9572(14)00741-2

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On parle beaucoup de l'apport de l'échographie en préhospitalier et plus particulièrement de l'échographie des voies aériennes. Ce travail réalisé dans un contexte de pédiatrie hospitalière est intéressant car il peut peut-être être transposé à nos besoins. Etre rapidement certain du caractère effectif de l'intubation peut être difficile. L'échographie peut être d'un apport important par la visualisation d'un glissement pleural bilatéral. On peut aussi gonfler le ballonnet de la sonde [Ce qui est fait lors de transports aériens non ou mal préssurisés], ce qui permettra d'observer non un cône d'ombre en arriere du ballonnet mais les structures anatomiques du fait de la transmissions des ondes permise par l'eau présente dans le ballonnet.

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OBJECTIVES: 

We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth.

METHODS:

We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth.

EchoAIrwayBallon.jpg

RESULTS:

Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s).

CONCLUSIONS:

Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.

29/12/2014

Vidéolaryngoscopie: Un tournant ?

Techniques, Success, and Adverse Events of Emergency Department Adult Intubations

Brown CA et Al. Ann Emerg Med. 2014;-:1-9.

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Une certitude, l'emploi de vidéolaryngoscope simplifie l'abord trachéal pour les praticiens les moins expérimentés. Reste à démocratiser au plan économique ces dispositifs.

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Study objective: We describe the operators, techniques, success, and adverse event rates of adult emergency department (ED) intubation through multicenter prospective surveillance.

Methods: Eighteen EDs in the United States, Canada, and Australia recorded intubation data onto a Web-based data collection tool, with a greater than or equal to 90% reporting compliance requirement. We report proportions with binomial 95% confidence intervals (CIs) and regression, with year as the dependent variable, to model change over time.

Results: Of 18 participating centers, 5 were excluded for failing to meet compliance standards. From the remaining 13 centers, we report data on 17,583 emergency intubations of patients aged 15 years or older from 2002 to 2012. Indications were medical in 65% of patients and trauma in 31%. Rapid sequence intubation was the first method attempted in 85% of encounters.VideoLaryngoUse.jpg Emergency physicians managed 95% of intubations and most (79%) were physician trainees. Direct laryngoscopy was used in 84% of first attempts. Video laryngoscopy use increased from less than 1% in the first 3 years to 27% in the last 3 years (risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year [ie, slope] 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine in 75% of rapid sequence intubations. Among rapid sequence intubations, rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3 years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last 3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2% to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI 99.3% to 99.6%).

Conclusion: In the EDs we studied, emergency intubation has a high and increasing success rate. Both drug and device selection evolved significantly during the study period.

 

 

| Tags : airway, intubation

22/12/2014

Plus d'auscultation mais une Echo ?

 Point of care ultrasound for orotracheal tube placement assessment in out-of hospital setting.

Zadel S et AL. Resuscitation. 2014 Nov 20;87C:1-6 

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A lire cet article, on comprend pourquoi l'engouement actuel pour l'échographie des voies aériennes. A coup sûr une technique à maîtriser en préhospitalier.

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AIM OF THE STUDY:

The percentage of unrecognised orotracheal tube displacement in an out-of-hospital setting has been reported to be between 4.8% and 25%. The aim of our study was to assess the sensitivity and specificity of Point-of-Care-UltraSound (POCUS) for confirming the propertube position after an urgent orotracheal intubation in an out-of-hospital setting and the time needed for POCUS.

METHODS:

Our single-centred prospective study included all patients who needed out-of-hospital orotracheal intubation. After the intubation, bilateral chest auscultation and assessment of bilateral lung sliding and diaphragm excursion within POCUS were done. Spectrographic quantitative capnography was used as the reference standard to confirm a proper tube position.

RESULTS:

We enrolled 124 patients. For auscultation, sensitivity and negative predicted value were 100%, specificity was 90% and positive predicted value 30% (95% confidence interval). 

EchoIntub.jpg

Sensitivity, specificity, positive predicted value, and negative predicted value for POCUS alone and for a combination of auscultation and POCUS were 100% (95% confidence interval). In three patients, we detected endobronchial tube displacement with auscultation and POCUS. Capnography failed to detect displacement in all three cases. The median time needed for POCUS was 30s.

CONCLUSION:

Results of our study support POCUS as an accurate and reliable method for confirming the proper orotracheal tube placement in trachea and it is feasible for out-of-hospital setting implementation. POCUS also seems to be time saving method but to make definitive conclusion more studies should be done.

15/12/2014

Anesthésie locale/régionale pour intubation

Regional and Topical Anesthesia for Endotracheal Intubation

Document Nisora

En cas d'intubation difficile, il est important de préserver la ventilation spontanée. Il existe pour cela plusieurs techniques qui vous sont présentées en quelques images. Ces techniques permettent de faciliter l'intubation en évitant 3 réflexes du tronc particuliers: le gag reflexe (réflexe nauséeux) médié par le nerf glossopharyngé, le réflexe de fermeture glottique médié par les nerfs récurrents et laryngés supérieurs et le réflexe de toux médié par le vague.

AirwayPicture1.jpg

1. L'anesthésie locale de glotte de proche en proche

AlProcheProche.jpg

2. La nébulisation d'anesthésique local

AlAérosol.jpg

3. Les blocs tronculaires

- a) Le bloc glossopharyngé

Anesthésie de l'oropharynx, de la portion postérieure de la langue et de la face antérieure de l'épiglotte

ALGPN.png

- b) Le bloc du nerf laryngé supérieur

Anesthésie de la base de la langue, de la surface postérieure de l'épiglotte, des replis aryépiglottiques et des aryténoïdes

ALHyoide.png

-c)  Le bloc transtrachéal des nerfs laryngés récurrents

anesthésie des cordes vocales et de la tachée

ALcrico.png

EN PRATIQUE solution 1 ou solution 2 ou association de 3b + 3c

Lire également:

Regional and Topical Anaesthesia of Upper Airways

Pani M et Al. Indian J Anaesth. Dec 2009; 53(6): 641–648.

 

14/12/2014

Sellick: Que disent les autres ?

La manoeuvre de Sellick

- Que disent les recommandations et RFE de nos sociétés savantes ?:

Cette manoeuvre est citée dans le document de la SFAR portant sur  la "Prise en charge des voies aériennes en anesthésie adulte, à l'exception de l'intubation difficile". Il y est dit qu'elle "peut gêner l’exposition glottique au cours d’une laryngoscopie directe". Elle l'est également dans le document portant sur l'intubation difficile ("Dans le cadre de l’urgence, l’ISR avec manoeuvre de Sellick est la technique de référence"). Dans la recommandation portant sur l'abord trachéal pour la ventilation mécanique des malades de réanimation il est indiqué qu'une "séquence d'induction anesthésique rapide (préoxygénation, administration IV d'un agent anesthésique et d'un curare d'action rapide, compression cricoïdienne) permet d'obtenir de bonnes conditions d'intubation et une protection des voies aériennes". Cette manoeuve est également recommandée dans le document portant sur lsédation et analgésie en structure d’urgence : "La pression cricoïdienne (hors contre-indication) débutée dès la perte de conscience et maintenu jusqu’à la vérification de la position de la sonde endotrachéale. Cette pression cricoïdienne doit être levée en cas de vomissement"

- L'intérêt de la manoeuvre de Sellick n'est cependant plus le même qu'il y a quelques années (123).

- Que lit on dans les recommandations étrangères ?

1. Chez les Sud Africains

Is cricoid pressure necessary ? [Rapid sequence intubation. Emergenc medicine society of South Africa EM015 EM015B]

" We don’t know – the evidence supporting the use of cricoid pressure is fairly limited and there is more and more evidence emerging about the damaging effects of this manoeuvre. It is acceptable to omit the use of cricoid pressure in RSI. It is also acceptable to use cricoid pressure, as long as it is released if it interferes with bag-mask ventilation or laryngoscopy. .

........ The use of cricoid pressure during RSI in the EC is controversial. The consensus of expert opinion at this point in time is that cricoid pressure should be applied after the patient has lost consciousness after the administration of the induction agent and continuously maintained until the cuff has been inflated and the position of the ETT has been confirmed to be correct. This guideline is subject to the following provisos:

• Cricoid pressure should not be used if the assistant is not trained and experienced with the procedure. EMSSA Practice Guidelines provide advice on recommended practice for emergency centres, emergency personnel and emergency care activities. The information within these papers statements is advice only. EMSSA will not be held liable for clinical outcomes related to these Guidelines

• Cricoid pressure should immediately be released and not reapplied if: o There is any difficulty in bag-mask ventilation. o A supraglottic airway device is inserted. o There is any difficulty with laryngoscopy, including if external laryngeal manipulation is required (which cannot be performed while maintaining effective cricoid pressure). o The patient vomits.

• The doctor may also elect not to make use of cricoid pressure at all during the RSI."

2. En Europe du nord

Pre-hospital airway management: Scandinavian Society for Anaesthesiology and Intensive Care Medicine 

Ils n'en parlent pas

3. Pour les suédois

Scandinavian clinical practice guidelines on general anaesthesia for emergency situations.

Jensenn AG et Al. Acta Anaesthesiol Scand 2010; 54: 922–950

"The use of cricoid pressure to reduce regurgitation is not based on scientific evidence. Therefore, its use cannot be recommended on the basis of scientific evidence. Anaesthesiologists can use the technique on individual judgement, but the anaesthesiologist must be ready to release the pressure if necessary. Cricoid pressure has been shown to limit the glottic view during laryngoscopy, and it should be releasedif such problems occur."

4. Pour les australiens 

Emergency Airway Management in the Trauma Patient

"In conscious patients the cricoid cartilage is palpated between the thumb and middle finger, with the index finger above. The cricoid cartilage is located just below the prominent thyroid cartilage (Adam’s apple). As anaesthesia is induced the pressure is increased in a vertical plane onto the vertebral body of C5. The amount of pressure needs to approximate to 30 Newtons, comparable to the pressure that would feel uncomfortable if applied to the bridge of the nose. Removal of cricoid pressure should only follow securing of the airway and the request of the person performing intubation."

5. Pour les anglais 

DAS RSI Intubation guidelines

"Cricoid force: 10N awake 30N anaesthetise. If poor view: Reduce cricoid force. If Failed intubation: Maintain 30N cricoid force. Consider reducing cricoid force if ventilation difficult. If failed oxygenation: Reduce cricoid force during insertion of the LMA"

6. Pour les canadiens

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

"As cricoid pressure is likely to have potential benefits, its continued use seems prudent during rapid sequence intubation in the patient at high risk of aspiration (Strong recommendation for, level of evidence C). However, if difficulty is encountered with face mask ventilation or tracheal intubation, or if SGD insertion is needed, progressive or complete release of cricoid pressure is justified."

7. Chez les US

Drug-Assisted Intubation in the Prehospital Setting (NAEMSP Position Statement)

"While we recommend the application of cricoid pressure, we note that there are presently no data to support the effectiveness of this technique during prehospital airway management."

| Tags : airway

19/11/2014

Une bougie dans la sonde: c'est mieux.

Comparison of Intubation Performance by Emergency Medicine Residents Using Gum Elastic Bougie versus Standard Stylet in Simulated Easy and Difficult Intubation Scenarios

Walsh RM et All. Emerg Med Australas - ; 26 (5); 446-9 

Study Objectives: We sought to evaluate the success rate and time to endotracheal intubation by emergency medicine residents with stylet reinforced endotracheal tube (ETT-S) versus intubation with a gum elastic bougie (GEB) in simulated easy and difficult airways on a cadaveric model.

 Methods: The study was a prospective cross-over design using a single study cohort of 29 emergency medicine residents. A fresh frozen cadaver was used in either standard positioning to facilitate a Cormack Lehane Grade 1 laryngoscopy, or with a hard cervical collar applied a Cormack Lehane Grade 3 laryngoscopy. Each participant then intubated the cadaver in each setting (Grade 1 ETT-S, Grade 1 GEB, Grade 3 ETT-S, Grade 3 GEB). The primary end-point of our investigation was the time to intubation. Secondary endpoints were: success rate of intubation, mean ratings by study participants of perceived ease of intubation for each intubation technique in each simulated degree of difficulty, and overall preference of intubation technique in each simulated degree of difficulty. To assess the effect of intubation type (GEB vs ETT-S) and difficulty on time to successful intubation and perceived ease of intubation, repeated measures ANOVAs were conducted. To examine whether success of intubation differed across the GEB and ETT-S groups we used a McNemar’s test. To examine the effect of previous experience on time to intubation, we used a mixed model ANOVA incorporating intubation type and difficulty of intubation.

Results: Mean time to intubation in all scenarios ranged from 28.8 – 116.6 seconds. Year of residency training trended toward significance but was not significant when comparing post-graduate year to time to intubation (p¼ 0.07). Time to intubation was significantly different only when comparing Grade 3 ETTS to Grade 3 GEB (p¼ 0.006). Of the 116 intubations performed in this study, a total of 36 were failed attempts. There was no significant difference in success rate when comparing Grade 1 ETT-S to Grade 1 GEB nor Grade 3 ETT-S to Grade 3 GEB (p ¼ >0.05). Across all year groups, participants perceived the Grade 1 scenario to be easier than the Grade 3 scenario. At the conclusions of the study, 55% of participants preferred using the GEB in all settings. When broken down by scenario, 41% preferred the GEB in the Grade 1 scenario while 76% preferred the GEB in the Grade 3 scenario.

Conclusions: Time to intubation in a simulated grade 3 view was significantly longer in the GEB group versus the ETT-S group. Although the differences in success rates were not statistically significant, there was a trend toward more successful intubations with the GEB in the simulated grade 3 view. This is important because in the emergency department when difficult airways can be high stress and life threatening, although the GEB group took more time, the success rates were higher.

| Tags : intubation

11/11/2014

Videolaryngoscope en préhospitalier ? Pas si évident !

What is the role of video laryngoscopy in prehospital care ?

Voelckel WG et Al. Scand J Trauma Resusc Emerg Med. 2014; 22(Suppl 1): A6

Une réflexion qui exprime, malgré un apprentissage plus rapide et une meilleure vision, le manque actuel de données sur l'intérêt de la vidéolaryngoscopie préhospitalière. En effet meilleure vision ne signifie pas insertion plus facile du tube trachéal dans la trachée (lire ces argumentaires: 1, 2, 3, 4). Les auteurs lui prédisent cependant une place importante dans les années à venir.et en attendant:

 APPRENEZ A INTUBER EN LARYNGOSCOPIE DIRECTE ET MAINTENEZ VOTRE SAVOIR FAIRE

| Tags : airway

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

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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).

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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

20/09/2014

Intubation face à face: Du nouveau ?

Comparison of Sitting Face-to-Face Intubation (Two-Person Technique) with Standard Oral-tracheal Intubation in Novices: A Mannequin Study

J Emerg Med. 2012 Dec;43(6):1188-95

FacetoFace Intubation.jpeg

L'intubation face au patient n'est pas une nouveauté que ce soit en préhospitalier ou au bloc opératoire. Elle est cependant très peu fréquemment mise en oeuvre. Pourtant l'apparition des vidéolaryngoscopes, notamment l'airtraq,  simplifie grandement cette pratique (vidéo ici). Certains s'interrogent sur son emploi plus large. Elle serait plus aisée que la laryngoscopie directe en décubitus dorsal. C'est ce que suggère ce document. Un grand recul est cependant nécessaire. Ce travail a été fait sur mannequin.

BACKGROUND:

Few studies have evaluated the impact of the upright position on the success of oral-tracheal intubation. Yet, for patients with airway difficulties (i.e, active intraoral bleeding or morbidly obese), the upright position may both benefit the patient and facilitate intubation.

OBJECTIVES:

We compared the success rates of subjects performing standard intubation to a modified version of the sitting face-to-face oral-tracheal intubation technique on a simulation model. We also reviewed the possible advantages and limitations of the sitting face-to-face intubationtechnique.

METHODS:

Volunteer medical and paramedical students were given instruction, then tested, performing in random order both standard oral-trachealand two-person sitting face-to-face oral-tracheal intubation on full-bodied mannequins. Observers reviewed video recordings, noting the number of successful intubations and the time to completion of each procedure at 15, 20, and 30 s.

RESULTS:

All of the sitting face-to-face intubations were successful, 53/53 (100%, 95% confidence interval [CI] 93-100%); whereas of the 53 subjects who performed standard intubation, 48 were successful (91%, 95% CI 80-96%). The difference between successful intubations using thestandard vs. sitting face-to-face technique was 9% (95% CI 1.3-9.4%, p=0.025). At times 15 and 20 s, medical student subjects who successfully performed both techniques were less successful at completing the procedure when performing the standard technique as compared to the sittingface-to-face technique (p=0.016). A post-procedural survey found that the majority of subjects preferred the sitting technique.

CONCLUSION:

Subjects were significantly more successful at performing and preferred the sitting face-to-face intubation when compared to standardintubation.

 

 

| Tags : airway

30/08/2014

Que font les israéliens en role 1

Role I trauma experience of the Israeli Defense Forces on the Syrian border

Benov A. et All. J Trauma Acute Care Surg. 2014 Sep;77(3 Suppl 2):S71-6

Une des particularités des actions conduites en role 1 par les équipes israéliennes est la maîtrise par leurs personnels des gestes de contrôle des voies aériennes, qu'il s'agisse de médecins ou de paramédic EMT-P. Cette publication l'illistre et confirme l'importance actuelle de ce savoir faire qui est donc ESSENTIEL pour une médicalisation réelle de l'avant.

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" Two-hundred fifty-eight casualties arrived at the border, 60 of whom were evaluated and returned to Syria. Of those, 15 received basic care and did not require any additional intervention, 39 experienced chronic conditions with no immediate need for medical attention, and 6 were dead on arrival. ......................Data from all echelons including prehospital information were available for 178 (90%) of the 198 patients, and this group constituted the study cohort. The extent of medical evacuation among the 178 casualtiesis as follows: 8 (4%) required only Role I care (debridement of wounds, removal of fragments, or death despite resuscitation attempts); 65 (36%) were evacuated to a Role 2+ facility and were later discharged; and 84 (47%) were evacuated to Role 3 civilian hospitals.  ................................Eighteen patients underwent advanced airway procedures. Of 14 patients with a documented oxygen saturation of less than 90%, 5 improved following oxygen supplementation and did not require airway intervention. Of the 18 patients undergoing definitive airway management, head and face injury was present in two thirds (n = 11) of these, whereas a quarter (n = 4) had thoracic injury. The procedures were endotracheal intubation (ETI) (n = n = 15) and cricothyroidotomy (CRIC) (n = 10). Seven of eight casualties underwent CRI following failed initial attempt at ETI, and one patient was able to have mask ventilation following failed ETI. In three cases, CRIC was the first choice of airway management, two patients experiencing severe maxillofacial injury and one with severe laryngeal edema. There were no cases of preventable death due to airway obstruction and no complications from airway interventions. Forty-three casualties experienced thoracic injuries, five underwent chest decompression at a Role I facility by either needle decompression (n = 3) or insertion of a chest drain (n = 2).

IDF Role1 lifeSaving Syria.jpg

 

| Tags : airway

03/07/2014

Dispositifs laryngés préhospitalier: Prudence !

Prehospital airway management using the laryngeal tube : An emergency department point of view.

Bernardht M. et Al Anaesthesist. 2014 Jul 2. [Epub ahead of print]

Il est proposé d'avoir recours à des dispositifs supra glottique pour la maîtrise de l'abord des voies aériennes en préhospitalier. Si ces dispositifs présentent des avantages avec notamment celui supposé d'une insertion plus simple que l'intubation ces derniers ont également des limites. AInsi l'engouement actuel doit il être tempéré par des inconvénients qui commencent à être décrits. C'est ce que rapporte l'article.

Parmi ceux ci, il y a les mauvais placement avec pour conséquence un défaut de ventilation du patient, un oedème obstructif de langue malgré des temps de pose court inférieur à 45 min et une situation d'intubation difficile, des problèmes d'étanchéité avec dans un cas une insufflation gastrique importante responsable d'un gêne à la ventilation contrôlée, un défaut de protection des voies aériennes avec inhalation du contenu gastrique.

Ce travail illustre donc que le recours aux dispositifs supraglottique ne doit pas être pensé comme une alternative à l'intubation qui permettrait à des opérateurs moins formés de pouvoir réaliser un geste de contrôle des voies aériennes. Il ne remet pas en cause l'intérêt de certains masques notamment les masques laryngés d'intubation qui on toute leur place dans la stratégie de gestion de l'intubation difficile. Enfin en condition de combat on rappelle que les 3 techniques dont la maîtrise doit être parfaite sont la ventilation manuelle, l'intubation oro-trachéale avec ISR et la coniotomie. Ceci est également le positionnement de l'armée israélienne.  On retrouve là, comme avec l'exsufflation des pneumothorax avec des aiguilles de 8 cm en lieu et place des cathéters courants, outre la prudence nécessaire à avoir face à des avantages apparents sans analyses des inconvénients associés.

BACKGROUND:

 

Competence in airway management and maintenance of oxygenation and ventilation represent fundamental skills in emergency medicine. The successful use of laryngeal tubes (LT, LT-D, LTS II) to secure the airway in the prehospital setting has been published in the past. However, some complications can be associated with the use of a laryngeal tube.

METHODS:

In a nonconsecutive case series, problems and complications associated with the use of the laryngeal tube in prehospital emergency medicine as seen by independent observers in the emergency room are presented.

RESULTS:

Various problems and possible complications associated with the use of a laryngeal tube in eight case reports are reported: incorrect placement of the laryngeal tube in the trachea, displacement and/or incorrect placement of the laryngeal tube in the pharynx, tongue and pharyngeal swelling with subsequently difficult laryngoscopy, and inadequate ventilation due to unrecognized airway obstruction and tension pneumothorax.

CONCLUSION:

Although the laryngeal tube is considered to be an effective, safe, and rapidly appropriable supraglottic airway device, it is also associated with adverse effects. In order to prevent tongue swelling, after initial prehospital or in-hospital placement of laryngeal tube and cuff inflation, it is important to adjust and monitor the cuff pressure.

| Tags : airway

13/06/2014

Airway Cam Portal

Airway Cam Portal

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| Tags : airway