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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).



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.


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.


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.


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


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.


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.


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.


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.


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.


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



| Tags : airway


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.


" 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


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.



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.


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.


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.


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


Airway Cam Portal

Airway Cam Portal

Cliquer sur l'image pour accéder au site

| Tags : airway


Réflexions US sur l'accès aux voies aériennes

Advances in prehospital airway management

 Jacobs PE et all. Int J Crit Illn Inj Sci. 2014 Jan-Mar; 4(1): 57–64.


Prehospital airway management is a key component of emergency responders and remains an important task of Emergency Medical Service (EMS) systems worldwide. The most advanced airway management techniques involving placement of oropharyngeal airways such as the Laryngeal Mask Airway or endotracheal tube. Endotracheal tube placement success is a common measure of out-of-hospital airway management quality. Regional variation in regard to training, education, and procedural exposure may be the major contributor to the findings in success and patient outcome. In studies demonstrating poor outcomes related to prehospital-attempted endotracheal intubation (ETI), both training and skill level of the provider are usually often low. Research supports a relationship between the number of intubation experiences and ETI success. National standards for certification of emergency medicine provider are in general too low to guarantee good success rate in emergency airway management by paramedics and physicians. Some paramedic training programs require more intense airway training above the national standard and some EMS systems in Europe staff their system with anesthesia providers instead. ETI remains the cornerstone of definitive prehospital airway management, However, ETI is not without risk and outcomes data remains controversial. Many systems may benefit from more input and guidance by the anesthesia department, which have higher volumes of airway management procedures and extensive training and experience not just with training of airway management but also with different airway management techniques and adjuncts.

| Tags : airway, intubation


Pression cricoïdienne: Plus recommandé

La manoeuvre de Sellick, si classique, n'est plus recommandée ou du moins il est considéré qu'elle ne dispose plus d'assez d'arguments pour en faire une manoeuvre obligatoire.

Cliquez sur l'image qui suit pour un point actualisé


Les recommandations de l'Eastern Association for the Surgery of Trauma

| Tags : intubation


Manoeuvre de Sellick: Questions/Réponses

Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis

Ellis DY et Al. An Emerg Med. 2007 Dec;50(6):653-65

La manœuvre de Sellick est une technique de compression du cartilage cricoïde, décrite en 1961 par Sellick BA. Lors de la réalisation d'une intubation trachéale, elle est utilisée pour prévenir le risque de régurgitation du contenu gastrique et œsophagien vers le pharynx et son inhalation bronchique et alvéolaire lors de l'induction anesthésique qui entraîne une dépression des réflexes de protection des voies aériennes, chez un patient dont l’estomac est plein.

Elle consiste à appuyer fermement sur le cartilage cricoïde qui va alors comprimer l'extrémité supérieure de l'œsophage dont les parois sont souples, contre le corps vertébral de la vertèbre cervicale sous-jacente, rigide. L'intensité de la force à exercer doit être d'environ 20 newtons (N) si le patient est conscient et de 30 N s'il est inconscient2. Cette force est suffisante pour prévenir la régurgitation (inefficace si inférieure à 10 N), n'entraîne pas de sensation nauséeuses susceptibles d'augmenter l'inhalation du contenu gastrique et met à l'abri d'une rupture œsophagienne.

Le taux d'efficacité de la manœuvre de Sellick n'est pas bien établi, techniquement simple, elle est pourtant souvent mal réalisée.


Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.



Le travail présenté répond à un certain nombre d'interrogations et précise pourquoi la réalisation de cette manoeuvre est remise en question.

| Tags : airway


Coniotomie au Combat: Simuler pour retenir le savoir

Effect of Simulation Training on Compliance with Difficult Airway Management Algorithms, Technical Ability, and Skills Retention for Emergency Cricothyrotomy

Vincent H. et Al. Anesthesiology 2014; 120:999-1008



The effectiveness of simulation is rarely evaluated. The aim of this study was to assess the impact of a short training course on the ability of anesthesiology residents to comply with current difficult airway management guidelines.


Twenty-seven third-year anesthesiology residents were assessed on a simulator in a "can't intubate, can't ventilate" scenario before the training (the pretest) and then randomly 3, 6, or 12 months after training (the posttest). The scenario was built so that the resident was prompted to perform a cricothyrotomy. Compliance with airway management guidelines and the cricothyrotomy's duration and technical quality were assessed as a checklist score [0 to 10] and a global rating scale [7 to 35].


After training, all 27 residents (100%) complied with the airway management guidelines, compared with 17 (63%) in the pretest (P < 0.005). In the pretest and the 3-, 6-, and 12-month posttests, the median [range] duration of cricothyrotomy was respectively 117 s [70 to 184], 69 s [43 to 97], 52 s [43 to 76], and 62 s [43 to 74] (P < 0.0001 vs. in the pretest), the median [range] checklist score was 3 [0 to 7], 10 [8 to 10], 9 [6 to 10], and 9 [4 to 10] (P < 0.0001 vs. in the pretest) and the median [range] global rating scale was 12 [7 to 22], 30 [20 to 35], 33 [23 to 35], and 31 [18 to 33] (P < 0.0001 vs. in the pretest). There were no significant differences between performance levels achieved in the 3-, 6-, and 12-month posttests.


CONCLUSION: The training session significantly improved the residents' compliance with guidelines and their performance of cricothyrotomy.


| Tags : airway, intubation


Airway en préhospitalier US: Plus tube que dispositif glottique

An update on out-of-hospital airway management practices in the United States

Diggs LA. et Al. Resuscitation. 2014 Mar 15. pii: S0300-9572


Ce document fait le point sur la pratique préhospitalière US. Cette dernière est faite avant tout d'intubation et la prudence est de mise concernant les performances réelles des dispositifs supra-glottiques avec lesquels (excepté le tube de king) les résultats sont moins bons.


OBJECTIVE: We characterized out-of-hospital airway management interventions, outcomes, and complications using the 2012 NEMSIS Public-Release Research Data Set containing almost 20 million Emergency Medical Services activations from 40 states and two territories. We compared the outcomes with a previous study that used 2008 NEMSIS data containing 16 states with 4 million EMS activations.


Patients who received airway management interventions including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and surgical) were identified. Using descriptive statistics, airway management success and complications were examined in the full cohort and key subsets including cardiac arrest, non-arrest medical, non-arrest injury, children<10 years, children 10-19 years, rapid sequence intubation (RSI), population setting, US census region, and US census division.


Among 19,831,189 EMS activations, there were 74,993 ETIs, 21,990 alternate airways, and 1332 cricothyroidotomies. ETI success rates were: overall 63,956/74,993 (85.3%; 95% CI: 85.0-85.5), cardiac arrest 33,558/39,270 (85.5%), non-arrest medical 12,215/13,611 (89.7%), non-arrest injury (90.1%), children<10 years 2069/2468 (83.8%), children 10-19 years 1647/1900 (86.7%), adults>19 years 58,965/69,144 (85.3%), and rapid sequence intubation 5265/5658 (93.1%). Major complications included bleeding 677 (4.4 per 1000 interventions), vomiting 1221 (8 per 1000 interventions), esophageal intubation immediately detected 874 (5.7 per 1000 interventions), and esophageal intubations other 219 (1.4 per 1000 interventions).




Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting. Only selected emergency medical procedures have proved to be safe and effective. The safety and efficacy profile of ETI has been challenged in the last ten years. Intubation has been the standard of care in the United States for more than thirty years and is regarded as one of the most important EMS procedures. In this study, we retrospectively examined the largest aggregate of EMS data currently available and observed low out-of-hospital ETI success rates.

ETI is a complex procedure requiring skilled choreography and numerous critical decisions and actions. In the absence of qualified personnel, or if ETI proves problematic, alternate airways are commonly employed. As more EMS systems embrace alternate airway devices in lieu of ETI, it is important to have a clear appreciation of the true success rates of airway procedures using these devices across a variety of patient characteristics and clinical settings. This study examined the most commonly used alternate airway devices including the Combitube, Esophageal Obturator Airway, Laryngeal Mask Airway, King Laryngeal Tube, and cricothyroidotomy and observed very low alternate airway success rates in the largest population sample to date. Alternate airway success rates were substantially lower than ETI success rates except for the King LT.

| Tags : airway, intubation


Bougie d'intubation: Pas toutes égales



Bougie-related airway trauma: dangers of the hold-up sign

Marson BA et Al. Anaesthesia 2014, 69, 219–223

Le bon positionnement d'un mandrin d'intubation est confirmé parles sensations de ressaut quand l'extrémité de ce dernier franchit les anneaux trachéaux et par le blocage de ce dernier dans l'arbre bronchique. Ce dernier signe est appelé "the hold up sign" par les anglo-saxons. Ce blocage confirme que le mandrin n'est pas intra-oesophagien auquel cas il n'existerait pas. Cette publication attire l'attention sur le danger potentiel de traumatisme trachéal.


The bougie is a popular tool in difficult intubations. The hold-up sign is used to confirm tracheal placement of a bougie. This study aimed to establish the potential for airway trauma when using this sign with an Eschmann reusable bougie or a Frova single-use bougie. Airways were simulated using a manikin (hold-up force) and porcine lung model (airway perforation force). Mean (SD) hold-up force (for airway lengths over the range 25–45 cm) of 1.0 (0.4) and 5.2 (1.1) N were recorded with the Eschmann and Frova bougies, respectively (p < 0.001). The mean (SD) force required to produce airway perforation was 0.9 (0.2) N with the Eschmann bougie and 1.1 (0.3) N with the Frova bougie (p = 0.11). It is possible to apply a force at least five times greater than the force required to produce significant trauma with a Frova single-use bougie. We recommend that the hold-up sign should no longer be used with single-use bougies. Clinicians should be cautious when eliciting this sign using the Eschmann re-usable bougie.


Il existe d'autres bougies que celle d'eschmann et de Frova comme l'Introes pocket bougie ou la traffic light bougie. Cette dernière apparaît très intéressante car permettant de limiter la longueur de mandrin inséré dans la trachée et partant le risque de perforation trachéale.

| Tags : intubation


Trauma ballistique de la face: 1/3 nécessitent un airway sécurisé

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: Results of an 11-year multi-institutional study of 720 patients


Shackford et All. J Trauma Acute Care Surg. 2014;76: 347-352


Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.


We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.


From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001).


GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.


| Tags : airway


Airway préhospitalier: L'approche israélienne

Prehospital intubation success rates among Israel Defense Forces providers: Epidemiologic analysis and effect on doctrine

Katzenell U. et All. J Trauma Acute Care Surg. 2013 Aug;75(2 Suppl 2):S178-83


Un taux de succès somme toute acceptable mais par la répétition des essais. Un algorithme simple puisqu'il ne fait appel qu'à 3 techniques: l'intubation, la coniotomie et la ventilation au masque. Les auteurs recommandent de ne pas se tromper de combat et d'éviter de rentrer dans celui de l'intubation si le contexte opérationnel est très présent. Au final assez proche de ce qui est prôné dans la procédure du sauvetage au combat.



Advanced airway management is composed of a set of vital yet potentially difficult skills for the prehospital provider, with widely different clinical guidelines. In the military setting, there are few data available to inform guideline development. We reevaluated our advanced airway protocol in light of our registry data to determine if there were a preferred maximum number of endotracheal intubation (ETI) attempts; our success with cricothyroidotomy (CRIC) as a backup procedure; and whether there were cases where advanced airway interventions should possibly be avoided.


This is a descriptive, registry-based study conducted using records of the Israel Defense Forces Trauma Registry at the research section of the Trauma and Combat Medicine Branch, Surgeon General's Headquarters. We included all casualties for whom ETI was the initial advanced airway maneuver, and the number of ETI attempts was known. Descriptive statistics were used.


Of 5,553 casualties in the Israel Defense Forces Trauma Registry, 406 (7.3%) met the inclusion criteria. Successful ETI was performed in 317 casualties (78%) after any number of ETI attempts; an additional 46 (11%) underwent CRIC, and 43 (11%) had advanced airway efforts discontinued. ETI was successful in 45%, 36%, and 31% of the first, second, and third attempts, respectively, with an average of 28% success over all subsequent attempts. CRIC was successful in 43 (93%) of 46 casualties in whom it was attempted. Of the 43 casualties in whom advanced airway efforts were discontinued, 29 (67%) survived to hospital discharge.

IDF Intubation.jpg


After the first ETI attempt, success with subsequent attempts tended to fall, with minimal improvement in overall ETI success seen after the third attempt. Because CRIC exhibited excellent success as a backup airway modality, we advocate controlling the airway with CRIC if ETI efforts have failed after two or three attempts. We recommend that providers reevaluate whether definitive airway control is truly necessary before each attempt to control the airway.


Rupture cricotrachéale: Que faire ?

Cricotracheal Separation after Gunshot to the Neck: Report of a Survivor with Recovery of Bilateral Vocal Fold Function.

Vivero RJ et Al.

Il s'agit d'une éventualité rarissime mais cette observation montre qu'en situation d'isolement extrême il peut être possible d'agir si la partie distale est visible. Encore faut il connaître l'existence de cette conduite à tenir.


Initial appropriate airway management is imperative to improve survival. Numerous case reports in the literature demonstrate incidental findings of airway injury after routine workup of the patient or the advent of ominous clinical findings (1,2) . At this stage in patient management, it can become difficult to adequately secure the airway, which places the patient at increased risk. A careful physical examination is therefore critical, with fiberoptic laryngoscopy used, as necessary, in the stable patient. A CT scan can be a useful adjunct in the clinical workup, but it should not be relied upon solely, as it can be inconclusive (3) . When cricotracheal separation is identified and the patient is stable, the airway should be secured surgically in the operating room or trauma bay. The proximal stump of the airway should be grasped and secured with a clamp, and then an awake tracheotomy performed (under local anesthesia if possible) distal to the injury. In the event that the patient is unstable or that intubation fails, the distal stump of the trachea should be identified either visually or by palpation. The stump of trachea should then be grasped with a clamp and pulled superficially (out of the wound toward the skin surface), and an appropriately sized endotracheal tube is placed as a temporary measure and secured. The clamp should not be removed from the airway, as the distal tracheal stump can retract into the mediastinum. The patient should then be taken to the operating room emergently for formal tracheotomy or maturation of the airway tracheostoma. In general, cricothyrotomy should not be performed, as this is usually proximal to the site of airway separation.

| Tags : airway


Voies aériennes: Avant tout une histoire de communication

Airway management: judgment and communication more than gadgets

Donati F. Can J Anesth/J Can Anesth (2013) 60:1035–1040


Un éditorial publié à l'occasion de la sortie des nouvelles recommandations canadiennes sur l'intubation difficile (1 et 2). Plein de on sens et de pragmatisme et au final de rigueur scientifique dans ce document qui insiste sur le facteur humain et non le facteur matériel. . Les points essentiels sont 

1.   le maintien de l’oxygènation est proposé comme objectif ultime de toute manœuvre au niveau des voies aériennes

Non pas 

"cannot intubate cannot ventilate"


"cannot intubate cannot oxygenate"

2.  Malgré la popularité croissante et l’utilisation répandue des dispositifs supraglottiques, l’intubation trachéale demeure l’étalon or et la méthode préférée pour une prise en charge stable des voies aériennes.

3.  La vidéolaryngoscopie n’est pas présentée comme la solution universelle à tous les problèmes liés aux voies aériennes

4. Le nombre de tentatives, quelle que soit la technique d’intubation ou la position, devrait se limiter à trois même si n’existe aucune donnée probante solide appuyant un tel énoncé.

5.  Même si il existe des données probantes selon lesquelles un accès chirurgical aux voies aériennes chirurgicales ne sauve pas toujours des vies, le groupe recommande d’essayer d’obtenir un accès chirurgical aux voies aériennes lorsque tous les autres types de tentative échouent.

| Tags : airway, oxygène


Intubation en préhospitalier : intérêt des nouvelles techniques

IOT difficile et les nouveaux outils en situation d’urgence ( où en est-on ? )

Les procédures validées

Combes X et All. Urgences - 2013

Points essentiels 

■ L’intubation en séquence rapide est la technique de sédation validée pour faciliter l’intubation en situation d’urgence.

■ La préoxygénation peut être réalisée par VNI chez le patient coopérant.

■ Les lames de laryngoscopes en plastique ne doivent pas être utilisées.

■ L’utilisation du mandrin long béquillé est parfaitement validée en situation d’urgence en cas d’intubation difficile sans difficulté de ventilation associées.

■ Le masque laryngé d’intubation Fastrach® est le dispositif de ventilation le plus utile en situation d’urgence.

■ Les vidéolaryngoscopes ne sont pas encore validées pour la prise en charge de l’intubation difficile en situation d’urgence.


■ Les dispositifs de cricothyroïdotomiee basée sur la technique de Seldinger sont à privilégier en situation d’urgence

| Tags : airway, intubation


Vidéo laryngoscopie: Du bien, on n'est pas étonné

voies aériennes

Anesth  Analg 2013;XX:XX–XX 

BACKGROUND:The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators.

METHODS:We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension.

voies aériennes

RESULTS:There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL. 

CONCLUSIONS:UEI using a VL as the primary device improved intubation success anddecreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.

| Tags : intubation, airway


Mieux voir pour mieux intuber. Un moyen simple surtout si on débute

Retrograde Light-guided Laryngoscopy for Tracheal Intubation. Clinical Practice and Comparison with Conventional Direct Laryngoscopy

Anesthesiology 2013; 118:XXX–XXX doi: 10.1097/ALN.0b013e31828877c0.

L'intubation orotrachéale nécessite un apprentissage réel. Une cinquantaine de procédures réussies sont nécessaires pour pouvoir considérer avoir la maîtrise de ce geste. De nombreux dispositifs permettent d'augmenter le taux de réussite (bougie, stylets lumineux, dispositifs laryngés, fibroscopie, vidéolaryngoscope). Ces dernières sont cependant onéreuses et pas forcément toujours disponibles. L'illumination transtrachéale et rétrograde du plan glottique pourrait avoir une certaine utilité en améliorant la visualisation de l'orifice glottique.


Compared with DL, the success rate was greater in the RLGL group for all five intubations (72% vs. 47%; rate difference, 25%; 95% CI [11.84–38.16%], P < 0.001). This was associated with a shorter time to glottic exposure (median [25th and 75th percentile]; 27 [15; 42] vs. 45 [30; 73] s, P < 0.001), shorter intubation time (66 [44; 120] vs. 120 [69; 120] s, P < 0.001), and decreased throat soreness (mean ± SD; visual analog scale, 2.1 ± 0.9 vs. 3.7 ± 1.0 cm, P = 0.001) in the RLGL group compared to the DL group.



| Tags : intubation, airway


Intubation: Encore une étude POUR

Comparison of Neurological Outcome between Tracheal Intubation and Supraglottic Airway Device Insertion of Out-of-hospital Cardiac Arrest Patients: A Nationwide, Population-based, Observational Study

J Emerg Med. 2013 Feb;44(2):389-97


The effect of prehospital use of supraglottic airway devices as an alternative to tracheal intubation on long-term outcomes of patients with out-of-hospital cardiac arrest is unclear.


We compared the neurological outcomes of patients who underwent supraglottic airway device insertion with those who underwent tracheal intubation.


We conducted a nationwide population-based observational study using a national database containing all out-of-hospital cardiac arrest cases in Japan over a 3-year period (2005-2007). The rates of neurologically favorable 1-month survival (primary outcome) and of 1-month survival and return of spontaneous circulation before hospital arrival (secondary outcomes) were examined. Multiple logistic regression analyses were performed to adjust for potential confounders. Advanced airway devices were used in 138,248 of 318,141 patients, including an endotracheal tube (ETT) in 16,054 patients (12%), a laryngeal mask airway (LMA) in 34,125 patients (25%), and an esophageal obturator airway (EOA) in 88,069 patients (63%).


The overall rate of neurologically favorable 1-month survival was 1.03% (1426/137,880). The rates of neurologically favorable 1-month survival were 1.14% (183/16,028) in the ETT group, 0.98% (333/34,059) in the LMA group, and 1.04% (910/87,793) in the EOA group. Compared with the ETT group, the rates were significantly lower in the LMA group (adjusted odds ratio 0.77, 95% confidence interval [CI] 0.64-0.94) and EOA group (adjusted odds ratio 0.81, 95% CI 0.68-0.96).

vas, intubation


Prehospital use of supraglottic airway devices was associated with slightly, but significantly, poorer neurological outcomes compared with tracheal intubation, but neurological outcomes remained poor overall.

| Tags : airway, intubation


L'intubation mieux qu'un dispositif supraglottique

Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest

Wang HE et all. Resuscitation 83 (2012) 1061–1066


Lors de la prise en charge préhospitalière d'un arrêt cardiaque il vaut mieux intuber que mettre en place un dispositif laryngé. Les conclusions de ce travail interpellent car elles vont à l'encontre de certaines propositions d'emploi de dispositifs laryngés pour le contrôle préhospitalier des voies aériennes. 



To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA.


We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out-of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders.


Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-h survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16).




In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.