Equipment and strategies for emergency tracheal access in the adult patient

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

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

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

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

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

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OBJECTIVE:

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

DESIGN:

Prospective crossover study.

SETTING:

University Sport Medicine Clinic.

PARTICIPANTS:

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

INTERVENTIONS:

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

MAIN OUTCOME MEASURES:

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

RESULTS:

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

CONCLUSIONS:

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

Videolaryngoscope as a standard intubation device

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

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

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

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

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

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

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

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

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

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

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OBJECTIVES:

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

DESIGN:

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

SETTING:

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

PATIENTS:

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

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

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

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

CONCLUSIONS:

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

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

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

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

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INTRODUCTION:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Evolution of Pararescue Medicine During Operation Enduring Freedom

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

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

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

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

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

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

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

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

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.

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

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

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

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.

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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.

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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).

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.

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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