Coniotomie: Plaidoyer UK pour la chirurgie

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective

Tyle T et Al. J R Army Med Corps. 2016 Jun 6. pii: jramc-2016-000637. doi: 10.1136/jramc-2016-000637

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Un geste peu fréquent: 86 blessés sur une période de 8 ans et pourtant un geste essentiel à maîtriser. Faire simple est mieux. Pour cela pas besoin d'être chirurgien, urgentiste ou anesthésiste-réanimateur.

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BACKGROUND:

The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway.

OBJECTIVE:

To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period.

METHODS:

A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05.

RESULTS:

86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge.

DISCUSSION:

Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

 

Crico: Incisez et palpez sous la peau !

Deficiencies in locating the cricothyroid membrane by palpation: We can’t and the surgeons can’t, so what now for the emergency surgical airway ?

Law JA et Al. Can J Anesth (2016) 63:791–796

"......Certaines questions concernant la localisation de la membrane cricothyroïdienne demeurent sans réponse. Nous savons désormais que la palpation externe manque de précision, indépendamment de la spécialité du médecin évaluateur. En d’autres termes, les techniques qui s’appuient sur un accès direct à la trachée via la membrane cricothyroïdienne palpée depuis l’extérieur (par ex., les techniques percutanées de Seldinger ou réalisées à l’aide d’un trocart, un accès basé sur un scalpel à l’aide d’une coupure horizontale unique) courent toutes le risque d’un mauvais positionnement. L’alternative, lorsqu’on a recours à ces techniques de cricothyrotomie (en fait, à toutes ces techniques), est de commencer par une incision verticale médiane de 3-4 cm à travers la peau et les tissus sous-cutanés situés sur l’emplacement estimé de la membrane cricothyroïdienne.5,6 La membrane cricothyroïdienne est ensuite palpée à nouveau dans la lésion, et son emplacement devrait être bien plus facile à déterminer lorsqu’il y a considérablement moins de tissu mou entre le doigt qui palpe et la membrane cricothyroïdienne. La cricothyrotomie peut ensuite se faire à l’aide de la technique choisie et en étant absolument certain de son bon positionnement......"

Crico: Utilisez le manche du bistouri !

Surgical Procedures in Trauma Management. New York, NY: Thieme Inc; 1986:303

Coniotomie: Chirurgicale SVP !

Emergency Cricothyrotomy Performed by Surgical Airway–naive Medical Personnel

Heymans F. et Al. Anesthesiology 2016; 125:00-00

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L'obstruction des voies aériennes est une cause rare mais évitable de décès au combat. savoir ouvrir un cou est donc un geste qui doit être maîtrisé par le médecin ou l'infirmier présent. Se pose cependant la question de la méthode: chirurgicale ou dispositif spécifique ? Ce travail apporte clairement une réponse. Des personnels de santé novice obtiennent de meilleurs résultats avec la technique chirurgicale. Même si la technique utilisée n'est pas celle promue par la procédure du sauvetage au combat (emploi d'un crochet de hook au lieu d'une pince de Monro-Kelly), ce travail conforte le choix qui est fait d'avoir recours à la technique chirurgicale. 

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Background: When conventional approaches to obtain effective ventilation and return of effective spontaneous breathing fail, surgical airway is the last rescue option. Most physicians have a limited lifetime experience with cricothyrotomy, and it is unclear what method should be taught for this lifesaving procedure. The aim of this study is to compare the performance of medical personnel, naive to surgical airway techniques, in establishing an emergency surgical airway in cadavers using three commonly used cricothyrotomy techniques.

Methods: Twenty medical students, without previous knowledge of surgical airway techniques, were randomly selected from their class. After training, they performed cricothyrotomy by three techniques (surgical, Merkel, and QuickTrach II) in a random order on 60 cadavers with comparable biometrics. The time to complete the procedure, rate of success, and number of complications were recorded. A success was defined as the correct placement of the cannula within the trachea in 3min.

 

"After intact skin palpation of relevant structures (step 1), a vertical midline skin incision (step 2) is emphasized because it can be extended up or down if not correctly placed and because fewer vessels are located at the midline. Although
rarely emphasized, we recommend finger palpation through the subcutaneous tissue (step 3) and even in the trachea as a guide, as a dissector, and as a dilator; finger palpation is oblivious to bleeding and a better guide to the ligament, being the “surgeon’s eye” during cricothyrotomy. A horizontal incision of the lower aspect of the cricotracheal ligament (step 4) allows for tension release and better opening. A hook permits to maintain the skin and the tracheal opening. Caudal traction (step 5) is recommended because the cricoid cartilage is more resistant and in order to prevent laryngeal injuries. We did not use a dilator, forceps, or a retractor during this experiment. Finally, a cuffed cannula is inserted (step 6)"

 

Results: The success rates were 95, 55, and 50% for surgical cricothyrotomy, QuickTrach, and Merkel, respectively (P = 0.025).

 

The majority of failures were due to cannula misplacement (15 of 20). In successful procedures, the mean procedure time was 94± 35 s in the surgical group, 77 ± 34 in the QuickTrach II group, and 149 ±24 in the Melker group (P < 0.001). Few significant complications were found in successful procedures. No cadaver biometric parameters were correlated with success of the procedure.

Conclusion: Surgical airway–naive medical personnel establish emergency cricothyrotomy more efficiently and safely with the surgical procedure than with the other two commonly used techniques

 

 

Echographie pour l'intubation: Plutôt oui.

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

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

BACKGROUND:

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

MATERIALS AND METHODS:

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

RESULTS:

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

DISCUSSION:

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

Maîtriser l'airway +++, entre autres

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

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

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

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

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STUDY OBJECTIVE:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Médicaliser: Pour faire quoi ?

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

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

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

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Background

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

Methods

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

Results

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

Conclusion

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

Intubation difficile: Reco UK

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

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Coniotomie: D'abord chirurgicale

Evaluation of novel Surgicric
cricothyroidotomy device

King W et Al. Anaesthesia. 2015 Nov 17. doi: 10.1111/anae.13275

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Ce travail est intéressant car il met en avant l'intérêt des techniques chirurgicales par rapport à une technique de référence qui est l'emploi du set de Melker et d'un nouveau kit: le Surgicric. Il montre également que la survenue de lésions de la paroi postérieure n'est pas une vue de l'esprit, cette complication étant la plus fréquente avec ce nouveau kit.

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A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric^® , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use.

The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.

 

Laryngoscopie directe: LA BASE

Videolaryngoscopy in trauma

Eggleton A. Anaesthesia 2015, 70, 1454–1466

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

Reference

1. Duggan LV, Griesdale DEG. Secondary cervical spine injury during airway management: beyond a one-size-fits-all

approach. Anaesthesia 2015; 70: 769–73

IOT: Affaire de tous et pas de spécialiste

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

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

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

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Objectives

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

Methods

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

Results

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

Conclusions

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

Abord trachéal: Point sur l'équipement

Equipment and strategies for emergency tracheal access in the adult patient

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

 

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

Airway: Pratiques UK en Helmand

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

Pugh HE et Al. J R Army Med Corps. 2015 Jun;161(2):121-6.

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Il faut savoir intuber et ouvrir un cou. Ce qui fait la médicalisation de l'avant n'est pas la présence d'un docteur  en médecine mais d'un professionnel de santé ayant la pratique de gestes de réanimation préhospitalière et capable de les mettre en oeuvre de faon opportune. La gestion des voies aériennes en est l'exemple. 

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OBJECTIVES:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to 'ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield'. The audit reference number is RCDM/Res/Audit/1036/12/0368.

CICO: Un cours en ligne

 

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Laryngoscope: Le manche compte

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

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

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

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OBJECTIVE:

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

DESIGN:

Prospective crossover study.

SETTING:

University Sport Medicine Clinic.

PARTICIPANTS:

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

INTERVENTIONS:

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

MAIN OUTCOME MEASURES:

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

RESULTS:

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

CONCLUSIONS:

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

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

Videolaryngoscope as a standard intubation device

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

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

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

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

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

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

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

Echo des voies aériennes

Focused ultrasound for airway management

http://viewer.zmags.com/publication/698570e2#/698570e2/1Tutoriel Philips

 

SANS HĖSITER: IL FAUT S'Y METTRE +++

Clic sur l'image pour accéder au document

Autres sources 1 2 3

Deux exemples

1. Visualisation de l'épiglotte:

- Vue transverse

- Vue parasagittale

2. Repérage du cartilage cricoïdienne en coupe sagittale ou parasagittale

 3. Réalisation d'une coniotomie

 

 

Crico: Plutôt avec une canule à ballonet

The Efficacy of Spontaneous and Controlled Ventilation With Various Cricothyrotomy Devices: A Quantitative In Vitro Assessment in a Model Lung

Michalek-Sauberer M et Al. J Trauma. 2011;71: 886 – 892

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La procédure du sauvetage au combat indique la réalisation d'une coniotomie en cas d'obstruction des voies aériennes. Le minitrach portex II doit être considéré plutôt comme un dispositif d'oxygénation. En effet il est rarissime que les obstructions soient complètes. Dans de telles conditions les fuites sont telle qu'une ventilation effective n'est pas possible sauf à utiliser un dispositif de jet ventilation de type manujet. L'article présenté exprime très bien les limites des dispositifs sans ballonet

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Background:

Guidelines for the management of a difficult airway recommend performing a cricothyrotomy in a “can’t intubate/can’t ventilate” situation. We investigated the tidal volumes delivered by controlled and spontaneous ventilation by seven commercially available cricothyrotomy sets (cuffed: Quicktrach II, Portex Cricothyroidotomy Kit, and Melker cuffed cannula and uncuffed: Airfree, 4.0-mm ID Quicktrach, 6.0-mm inner diameter Melker, and 13-gauge Ravussin cannula) and two improvised devices (14-gauge intravenous cannula and spike and drip chamber device).

Methods:

A LS800 model lung, set at different values for compliance and resistance and modified with different upper airway diameter, was ventilated via the respective cricothyrotomy device mechanically and using a selfinflating bag. With the 13-gauge Ravussin cannula and the 14-gauge intravenous cannula, a Manujet injector was used for jet ventilation. Spontaneous ventilation was simulated with a Michigan 560i lung.

Results:

During controlled or manual ventilation, all cuffed cricothyrotomy devices yielded adequate tidal volumes. Uncuffed devices provided tidal volumes
300 mL only with an upper airway diameter of 3 mm. With a Manujet injector, adequate tidal volumes required an upper airway diameter between 3 mm and 5 mm. A spike and drip chamber device does not provide suitable emergency airway access. Spontaneous ventilation at adequate inspiratory pressure levels required a device inner diameter of at least 4 mm.

 

 

Conclusion:

As expected, cuffed cricothyrotomy devices yield the best results during controlled, manual, and spontaneous ventilation. With uncuffed cricothyrotomy devices, ventilation becomes ineffective when the upper airway obstruction allows for an upper airway diameter
3 mm.

 

Coniotomie: Pas si simple à enseigner

 Cricothyroidotomy Bottom–Up Training Review: Battlefield Lessons Learned

Benett BL et Al. Military Medicine, 176, 11:1311, 2011 

Challenges with surgical cricothyroidotomy on the battlefi eld can be attributed to limited frequency of use, procedure unfamiliarity, and limited knowledge base of anatomical landmarks of which is further heighten in the tactical environment. The objective was to identify ways to enhance the cricothyroidotomy training to minimize potential preventable procedural errors. A training review was conducted to determine the gaps in the cricothyroidotomy training in a 4-day Tactical Combat Casualty Care course at the Naval Medical Center Portsmouth. An ad hoc Working Group team identified five specific gap areas in the cricothyroidotomy training: 1) limited gross airway anatomy review; 2) lack of “hands-on” human laryngeal anatomy; 3) nonstandardized step-by-step surgical incision skill procedure; 4) inferior standards for anatomically correct cricothyroid mannequins; 5) lack of standardized refresher training frequency. Specific training enhancements are recommended across each day in the classroom, simulation laboratory, and field exercise. 

Intubation: L'exemple des paramedic

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

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

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

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OBJECTIVES:

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

DESIGN:

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

SETTING:

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

PATIENTS:

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

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

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

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.