Intubation par les paramedic: Affaire de formation et de pratique

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.

 

Coniotomie sur le terrain: La vraie vie

An analysis of battlefield cricothyrotomy in Iraq and Afghanistan

J Spec Oper Med. 2012 Spring;12(1):17-23

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Pouvoir oxygéner est fondamental. Mais il existe de très nombreuses situations où l'oxygénation par masque ou ballon n'est pas possible ou insuffisante. Il faut alors contrôler les voies aériennes, en particulier la la réalisation d'une coniotomie (1). Ce travail est un des rares actuellement publiés qui fasse le point sur la réalisation de ce geste en conditions de combat (2,3,). Il met en avant la réalité de sa réalisation y compris par les medic, qui ont cependant un taux d'échec double de celui des médecins. Il suggère également tout l'intérêt des ateliers de formation et de séjours au bloc opératoire pour améliorer cet état de fait.

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OBJECTIVES:

Historical review of modern military conflicts suggests that airway compromise accounts for 1,2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting.

METHODS:

This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined successful if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patient's record were also noted in the review.

RESULTS:

Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PCs failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PCs (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement.

CONCLUSIONS:

The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

Vidéolaryngoscopie: Oui au moins dans les hélico !

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.

Intubation difficile: La vision canadienne actualisée

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

 

Reco US Intubation difficile

 

La mâchoire en avant: Mieux pour intuber !

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

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

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

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

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

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

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

 

Simulateurs d'airway: Fiables ?

A radiographic comparison of human airway anatomy and airway manikins – Implications for manikin-based testing of artificial airways

Schalk R et Al. Resuscitation. 2015 May 11. pii: S0300-9572(15)00199-9

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La maîtrise des techniques de contrôle des voies aériennes est un des enjeux de la médecine préhospitalière militaire. Le recours à la simulation est devenu très fréquent. Pour autant ce travail montre que cette méthode d'apprentissage a ses limites. L'une d'entre elle est le fait que les simulateurs de tache ne reproduisent pas correctement l'anatomie des voies aériennes.

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Objective

The aim of this prospective, single-center, observational study was to investigate the accuracy of modeling and reproduction of human anatomical dimensions in manikins by comparing radiographic upper airway measurements of 13 different models with humans.

Methods

13 commonly used airway manikins (male or female anatomy based) and 47 controls (adult humans, 37 male, 10 female) were investigated using a mediosagittal and axial cervical spine CT scan. For anatomical comparison six human upper airway target structures, the following were measured: Oblique diameter of the tongue through the center, horizontal distance between the center point of the tongue and the posterior pharyngeal wall, horizontal distance between the vallecula and the posterior pharyngeal wall, distance of the upper oesophageal orifice length of epiglottis distance at the narrowest part of the trachea. Furthermore, the cross-section of the trachea in axial view and the cross-section of the upper oesophageal orifice in the same section was calculated. All measurements were compared gender specific, if the gender was non-specified with the whole sample.

Results

None of the included 13 different airway manikins matched anatomy in human controls ( n = 47) in all of the six measurements. The Laerdal Airway Management Trainer, however, replicated human airway anatomy at least satisfactorily.

Conclusion

This investigation showed that all of the examined manikins did not replicate human anatomy. Manikins should therefore be selected cautiously, depending on the type of airway securing procedure. Their widespread use as a replacement for in vivo trials in the field of airway management needs to be reconsidered.

 

 

CICO: Stratégies et équipement

Equipment and strategies for emergency tracheal access in the adult patient

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

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

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

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

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

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

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

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

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

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

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

Airway et Echographie

 

Clic sur l'image pour accéder au document

 

 

Sellick: Mieux vaut être formé pour faire.

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

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

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

Clic sur l'image pour accéder au document

 

Intubation préhospitalière: Être conscient du temps qui passe

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

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

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

 

clic sur l'image pour accéder au document

Coniotomie: C'est du SC2 et il faut s'entraîner

Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study.

Barnard EBG et All. J Spec Oper Med. 2014 Winter;14(4):35-9

INTRODUCTION:

Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting.

METHODS:

The Life-Saving Intervention (LSI) study is a prospective, institutional review board-approved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at p <.05. The primary outcome was success of prehospital and en route cricothyrotomy.

RESULTS:

Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3?7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; p <.0011).

CONCLUSION:

In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

 

Airway aux urgences en Corée: Avec quoi ?

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

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

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

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BACKGROUND:

 

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

OBJECTIVES:

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

METHODS:

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

RESULTS:

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

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.

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

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

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

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

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OBJECTIVES: 

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Vidéolaryngoscopie: Un tournant ?

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

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

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

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

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

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

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

 

 

Plus d'auscultation mais une Echo ?

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

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

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

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AIM OF THE STUDY:

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

METHODS:

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

RESULTS:

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

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

CONCLUSION:

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

Sellick: Que disent les autres ?

La manoeuvre de Sellick

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

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

- L'intérêt de la manoeuvre de Sellick n'est cependant plus le même qu'il y a quelques années (1, 2, 3).

- Que lit on dans les recommandations étrangères ?

1. Chez les Sud Africains

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

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

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

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

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

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

2. En Europe du nord

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

Ils n'en parlent pas

3. Pour les suédois

Scandinavian clinical practice guidelines on general anaesthesia for emergency situations.

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

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

4. Pour les australiens 

Emergency Airway Management in the Trauma Patient

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

5. Pour les anglais 

DAS RSI Intubation guidelines

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

6. Pour les canadiens

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

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

7. Chez les US

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

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

Coniotomie: Quel diamètre ?

Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy

 Prithishkumar IJ et Al. Emergency Medicine Australasia (2010) 22, 13–20

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L'anatomie de la membrane cricoïdienne fait l'objet de nombreuses description. Un des intérêts de ces dernières est de préciser la taille de cette dernière et d'en déduire le diamètre de canule/sonde le plus adapté pour une insertion intratrachéale. Il existe de grandes variations selon les populations étudiées, ici indienne. On peut retenir pour  notre population militaire essentiellement masculine une hauteur de  6 mm pour une largeur de 8 mm. C'est pourquoi la taille maximale des canules insérées à ce niveau ne doit excéder ces dimensions.

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Objective: To measure the working dimensions of the cricothyroid membrane in the adult south Indian population and to establish the association between the working dimensions and the appropriate endotracheal tube size for the purpose of cricothyroidotomy.

Methods: Cross-sectional evaluation of 50 fresh adult autopsy cases (35 men, 15 women) in a medical university teaching hospital in South India.

Results: Age ranged from 17.0 to 83.0 years. Working dimensions of the membrane in neutral position of neck, in men: width = 8.41  2.11 mm, height = 6.57  1.87 mm; in women: width = 6.30  1.29 mm, height = 5.80  1.56 mm. Depth of the subglottic larynx at the level of cricoid cartilage: men = 20.73  1.97 mm, women = 15.62  1.71 mm. Distance of the lower border of cricothyroid membrane from suprasternal notch in neutral position of neck, in men = 5.18  1.76 cm, women = 4.72  1.55 cm; in passively extended neck, men = 7.86  1.25 cm, women = 8.05  1.28 cm. Regression equations have been derived to determine endotracheal tube size for cricothyroidotomy, based on distance between sternal  notch and chin, and height of the individual (P < 0.05).

Conclusions: Working dimensions are smaller in the Indian group compared with western publications. Endotracheal tubes ranging from size 3.0 to 6.0 might be used for cricothyroidotomy in the adult south Indian population. 

Videolaryngoscope en préhospitalier ? Pas si évident !

What is the role of video laryngoscopy in prehospital care ?

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

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

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