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1.  Rapid sequence intubation in Scottish urban emergency departments 
Objective: Airway care is the cornerstone of resuscitation. In UK emergency department practice, this care is provided by anaesthetists and emergency physicians. The aim of this study was to determine current practice for rapid sequence intubation (RSI) in a sample of emergency departments in Scotland.
Methods: Two year, multicentre, prospective observational study of endotracheal intubation in the emergency departments of seven Scottish urban teaching hospitals.
Results: 1631 patients underwent an intubation attempt in the emergency department and 735 patients satisfied the criteria for RSI. Emergency physicians intubated 377 patients and anaesthetists intubated 355 patients. There was no difference in median age between the groups but there was a significantly greater proportion of men (73.2% versus 65.3%, p=0.024) and trauma patients (48.5% versus 37.4%, p=0.003) in the anaesthetic group. Anaesthetists had a higher initial success rate (91.8% versus 83.8%, p=0.001) and achieved more good (Cormack-Lehane Grade I and II) views at laryngoscopy (94.0% versus 89.3%, p=0.039). There was a non-significant trend to more complications in the group of patients intubated by emergency physicians (8.7% versus 12.7%, p=0.104). Emergency physicians intubated a higher proportion of patients with physiological compromise (91.8% versus 86.1%, p=0.027) and a higher proportion of patients within 15 minutes of arrival (32.6% versus 11.3%, p<0.0001).
Conclusion: Anaesthetists achieve more good views at laryngoscopy with higher initial success rates during RSI. Emergency physicians perform RSI on a higher proportion of critically ill patients and a higher proportion of patients within 15 minutes of arrival. Complications may be fewer in the anaesthetists' group, but this could be related to differences in patient populations. Training issues for RSI and emergency airway care are discussed. Complication rates for both groups are in keeping with previous studies.
doi:10.1136/emj.20.1.3
PMCID: PMC1726022  PMID: 12533357
2.  LMA Supreme for neonatal resuscitation: study protocol for a randomized controlled trial 
Trials  2014;15:285.
Background
The most important action in the resuscitation of a newborn in the delivery room is to establish effective assisted ventilation. The face mask and endotracheal tube are the devices used to achieve this goal. Laryngeal mask airways that fit over the laryngeal inlet have been shown to be effective for ventilating newborns at birth and should be considered as an alternative to facemask ventilation or endotracheal intubation among newborns weighing >2,000 g or delivered ≥34 weeks’ gestation. A recent systematic review and meta-analysis of supraglottic airways in neonatal resuscitation reported the results of four randomized controlled trials (RCTs) stating that fewer infants in the group using laryngeal mask airways required endotracheal intubation (1.5%) compared to the group using face masks (12.0%). However, there were methodological concerns over all the RCTs including the fact that the majority of the operators in the trials were anesthesiologists.
Our hypothesis is based on the assumption that ventilating newborns needing positive pressure ventilation with a laryngeal mask airway will be more effective than ventilating with a face mask in a setting where neonatal resuscitation is performed by midwives, nurses, and pediatricians. The primary aim of this study will be to assess the effectiveness of the laryngeal mask airway over the face mask in preventing the need for endotracheal intubation.
Methods/design
This will be an open, prospective, randomized, single center, clinical trial. In this study, 142 newborns weighing >1,500 g or delivered ≥34 weeks gestation needing positive pressure ventilation at birth will be randomized to be ventilated with a laryngeal mask airway (LMA SupremeTM, LMA Company, UK - intervention group) or with a face mask (control group). Primary outcome: Proportion of newborns needing endotracheal intubation. Secondary outcomes: Apgar score at 5 minutes, time to first breath, onset of the first cry, duration of resuscitation, death or moderate to severe hypoxic-ischemic encephalopathy within 7 days of life.
Trial registration
ClinicalTrials.gov identifier: NCT01963936 (October 11, 2013).
doi:10.1186/1745-6215-15-285
PMCID: PMC4223364  PMID: 25027230
Laryngeal mask; Resuscitation; Positive pressure ventilation; Newborn infant
3.  Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study 
Introduction
Airway management is an important component of cardiopulmonary resuscitation (CPR). Recent guidelines recommend keeping any interruptions of chest compressions as short as possible and not lasting more than 10 seconds. Endotracheal intubation seems to be the ideal method for establishing a secure airway by experienced providers, but emergency medical technicians (EMT) often lack training and practice. For the EMTs supraglottic devices might serve as alternatives.
Methods
40 EMTs were trained in a 1-hour standardised audio-visual lesson to handle six different airway devices including endotracheal intubation, Combitube, EasyTube, I-Gel, Laryngeal Mask Airway and Laryngeal tube. EMTs performances were evaluated immediately after a brief practical demonstration, as well as after 1 and 3 months without any practice in between, in a randomised order. Hands-off time was pair-wise compared between airway devices using a repeated-measures mixed-effects model.
Results
Overall mean hands-off time was significantly (p<0.01) lower for Laryngeal tube (6.1s; confidence interval 5.2-6.9s), Combitube (7.9s; 95% CI 6.9-9.0s), EasyTube (8.8s; CI 7.3-10.3s), LMA (10.2s; CI 8.6-11.7s), and I-Gel (11.9s; CI 10.2-13.7s) compared to endotracheal intubation (39.4s; CI 34.0-44.9s). Hands-off time was within the recommended limit of 10s for Combitube, EasyTube and Laryngeal tube after 1 month and for all supraglottic devices after 3 months without any training, but far beyond recommended limits in all three evaluations for endotracheal intubation.
Conclusion
Using supraglottic airway devices, EMTs achieved a hands-off time within the recommended time limit of 10s, even after three months without any training or practice. Supraglottic airway devices are recommended tools for EMTs with lack of experience in advanced airway management.
doi:10.1186/1757-7241-21-10
PMCID: PMC3598524  PMID: 23433462
Anaesthesia; Emergency medical technicians; Hands-off time; Endotracheal intubation; Supraglottic airways; Emergency airway management; CPR
4.  Influence of airway management strategy on "no-flow-time" during an "Advanced life support course" for intensive care nurses – A single rescuer resuscitation manikin study 
Background
In 1999, the laryngeal tube (VBM Medizintechnik, Sulz, Germany) was introduced as a new supraglottic airway. It was designed to allow either spontaneous breathing or controlled ventilation during anaesthesia; additionally it may serve as an alternative to endotracheal intubation, or bag-mask ventilation during resuscitation. Several variations of this supraglottic airway exist. In our study, we compared ventilation with the laryngeal tube suction for single use (LTS-D) and a bag-mask device. One of the main points of the revised ERC 2005 guidelines is a low no-flow-time (NFT). The NFT is defined as the time during which no chest compression occurs. Traditionally during the first few minutes of resuscitation NFT is very high. We evaluated the hypothesis that utilization of the LTS-D could reduce the NFT compared to bag-mask ventilation (BMV) during simulated cardiac arrest in a single rescuer manikin study.
Methods
Participants were studied during a one day advanced life support (ALS) course. Two scenarios of arrhythmias requiring defibrillation were simulated in a manikin. One scenario required subjects to establish the airway with a LTS-D; alternatively, the second scenario required them to use BMV. The scenario duration was 430 seconds for the LTS-D scenario, and 420 seconds for the BMV scenario, respectively. Experienced ICU nurses were recruited as study subjects. Participants were randomly assigned to one of the two groups first (LTS-D and BMV) to establish the airway. Endpoints were the total NFT during the scenario, the successful airway management using the respective device, and participants' preference of one of the two strategies for airway management.
Results
Utilization of the LTS-D reduced NFT significantly (p < 0.01). Adherence to the time frame of ERC guidelines was 96% in the LTS-D group versus 30% in the BMV group. Two participants in the LTS-D group required more than one attempt to establish the LTS-D correctly. Once established, ventilation was effective in 100%. In a subjective evaluation all participants preferred the LTS-D over BMV to provide ventilation in a cardiac arrest scenario.
Conclusion
In our manikin study, NFT was reduced significantly when using LTS-D compared to BMV. During cardiac arrest, the LTS-D might be a good alternative to BMV for providing and maintaining a patent airway. For personnel not experienced in endotracheal intubation it seems to be a safe airway device in a manikin use.
doi:10.1186/1471-227X-8-4
PMCID: PMC2324096  PMID: 18402652
5.  Airway Trauma in a High Patient Volume Academic Cardiac Electrophysiology Laboratory Center 
Anesthesia and analgesia  2012;116(1):112-117.
Background
Providing anesthesia and managing airways in the electrophysiology suite can be challenging because of its unique setting outside of the conventional operating room. We report our experience of several cases of reported airway trauma including tongue and pharyngeal hematoma and vocal cord paralysis in this setting.
Methods
We analyzed all of the reported airway trauma cases between December 2009 and January 2011 in our cardiac electrophysiology laboratories, and compared these cases to those without airway trauma. Data from 87 cases, including 16 cases with reported airway trauma (trauma group) and 71 cases without reported airway trauma from the same patient population pool at the same time period (control group), were collected via review of medical records.
Results
Airway trauma was reported for 16 patients (0.7%) in 14 months among 2434 anesthetic cases. None of these patients had life-threatening airway obstruction. The avoidance of muscle relaxants during induction in patients with a body mass index less than 30 was found to be a significant risk factor for airway trauma (p=0.04, odds ratio 10, 95% confidence interval 1.1 to 482). Tongue or soft tissue bite occurred in two cases where soft bite block was not used during cardioversion. No statistically significant difference was found between the trauma and control groups for preprocedure anticoagulation, anticoagulation during the procedure, or reversal of heparin at the end of the procedure.
Conclusion
The overall incidence of reported airway trauma was 0.7% in our study population. Tongue injury was the most common airway trauma. The cause seems to have been multifactorial; however, airway management without muscle relaxant emerged as a potential risk factor. Intubation with muscle relaxant is recommended, as is placing a soft bite block and ensuring no soft tissue is between the teeth before cardioversion.
doi:10.1213/ANE.0b013e31826f9125
PMCID: PMC3530138  PMID: 23223101
6.  Advances in prehospital airway management 
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.
doi:10.4103/2229-5151.128014
PMCID: PMC3982372  PMID: 24741499
Airway; anesthesiology; emergency; management; prehospital
7.  Cardiorespiratory arrest in children (out of hospital) 
Clinical Evidence  2007;2007:0307.
Introduction
Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two thirds of arrests occurring in children under 18 months of age. Approximately 40% of cases have undetermined causes, including sudden infant death syndrome. Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for non-submersion out-of-hospital cardiorespiratory arrest in children? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 13 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: airway management and ventilation (bag-mask ventilation and intubation), bystander cardiopulmonary resuscitation, direct-current cardiac shock, hypothermia, intravenous sodium bicarbonate, standard dose of intravenous adrenaline (epinephrine), and training parents to perform resuscitation.
Key Points
Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two thirds of arrests occurring in children under 18 months of age. Approximately 40% of cases have undetermined causes, including sudden infant death syndrome . Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.
Overall survival for out-of-hospital cardiorespiratory arrest in children is poor. Overall survival for children who sustain cardiorespiratory arrest outside hospital not caused by submersion in water is about 5%.Of those who survive, between half and three quarters will have moderate to severe neurological sequelae.
There is very poor evidence for any intervention in cardiorespiratory arrest in children. Placebo-controlled trials would be unethical, and few observational studies have been performed.
Immediate airway management, ventilation, and high-quality chest compressions with minimal interruption are widely accepted to be key interventions. Ventilation with a bag and mask seems to be as effective as intubation. The most suitable method for the situation should be used.
Direct current cardiac shock is likely to be beneficial in children with ventricular fibrillation or pulseless ventricular tachycardia. Ventricular fibrillation or pulseless ventricular tachycardia are the underlying rhythms in 10% of cardiorespiratory arrests in children, and are associated with a better prognosis than asystole or pulseless electrical activity.Defibrillation within 10 minutes of the arrest may improve the outcome.
Intravenous adrenaline is widely accepted to be the initial medication of choice in an arrest. The standard dose of intravenous adrenaline is 0.01 mg/kg.Weak evidence suggests that higher-dose adrenaline (0.1 mg/kg) is no more effective in improving survival.The effects of cooling a child after arrest are unknown.
PMCID: PMC2943773  PMID: 19450304
8.  Cardiorespiratory arrest in children (out of hospital) 
Clinical Evidence  2010;2010:0307.
Introduction
Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two-thirds of arrests occurring in children under 18 months of age. Approximately 45% of cases have undetermined causes, including sudden infant death syndrome. Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.
Methods and outcomes
We conducted a systematic review aiming to answer the following clinical question: What are the effects of treatments for non-submersion out-of-hospital cardiorespiratory arrest in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 15 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: airway management and ventilation (bag–mask ventilation and intubation), bystander cardiopulmonary resuscitation, direct-current cardiac shock, hypothermia, intravenous sodium bicarbonate, standard dose of intravenous adrenaline (epinephrine), and training parents to perform resuscitation.
Key Points
Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two-thirds of arrests occurring in children under 18 months of age. Approximately 45% of cases have undetermined causes, including sudden infant death syndrome. Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.
Overall survival for out-of-hospital cardiorespiratory arrest in children is poor. Overall survival for children who sustain cardiorespiratory arrest outside hospital not caused by submersion in water is about 4%.Of those who survive, between half and three-quarters will have moderate to severe neurological sequelae.
There is very poor evidence for any intervention in cardiorespiratory arrest in children. Placebo-controlled trials would be unethical, and few observational studies have been performed.
Immediate airway management, ventilation, and high-quality chest compressions with minimal interruption are widely accepted to be key interventions. Ventilation with a bag and mask seems as effective as intubation. The most suitable method for the situation should be used.
Direct current cardiac shock is likely to be beneficial in children with ventricular fibrillation or pulseless ventricular tachycardia. Ventricular fibrillation or pulseless ventricular tachycardia are the underlying rhythms in 10% of cardiorespiratory arrests in children, and are associated with a better prognosis than asystole or pulseless electrical activity.Defibrillation within 10 minutes of the arrest may improve the outcome.
Intravenous adrenaline is widely accepted to be the initial medication of choice in an arrest. The standard dose of intravenous adrenaline is 0.01 mg/kg.Weak evidence suggests that higher dose adrenaline (0.1 mg/kg) is no more effective in improving survival.The effects of cooling a child after arrest are unknown.
PMCID: PMC3217789  PMID: 21406131
9.  Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study 
Introduction
We report data from the first Utstein-style study of physician-provided pre-hospital advanced airway management.
Materials and methods
Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) prospectively registered data according to the template for reporting data from pre-hospital advanced airway management. Data collection took place from February 1st 2011 to October 31st 2012. Included were patients of all ages on whom pre-hospital advanced airway management was performed. The objective was to estimate the incidences of failed and difficult pre-hospital endotracheal intubation, and complications related to pre-hospital advanced airway management.
Results
The overall incidence of successful pre-hospital endotracheal intubation among 636 intubation attempts was 99.7%, even though 22.4% of pre-hospital endotracheal intubations required more than one intubation attempt. The overall incidence of complications related to pre-hospital advanced airway management was 7.9%. Following rapid sequence intubation, the incidence of first pass success was 85.8%, the overall incidence of complications was 22.0%, the incidence of hypotension 7.3% and that of hypoxia 5.3%. Multiple endotracheal intubation attempts were associated with an increased overall incidence of complications. No airway management related deaths occurred.
Discussion
The overall incidence of successful pre-hospital endotracheal intubations compares to those found in other physician-staffed pre-hospital systems. The incidence of pre-hospital endotracheal intubations requiring more than one attempt is higher than suspected. The incidence of hypotension or hypoxia after pre-hospital rapid sequence intubation compares to those found in UK emergency departments.
Conclusion
Pre-hospital advanced airway management including pre-hospital endotracheal intubation performed by experienced anaesthesiologists is associated with high success rates and relatively low incidences of complications. An increased first pass success rate following pre-hospital endotracheal intubation may further reduce the incidence of complications and enhance patient safety in our system.
doi:10.1186/1757-7241-21-58
PMCID: PMC3733626  PMID: 23883447
Pre-hospital; Out-of-hospital; Prehospital emergency care (MeSH); Emergency medical services (MeSH); Helicopter emergency medical service; Critical care (MeSH); Airway management (MeSH); Endotracheal intubation (MeSH); Difficult endotracheal intubation; Complications (MeSH); Patient safety
10.  Maxillofacial trauma patient: coping with the difficult airway 
Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.
doi:10.1186/1749-7922-4-21
PMCID: PMC2693512  PMID: 19473497
11.  The Relationship Between Out-of-Hospital Airway Management and Outcome Among Trauma Patients with Glasgow Coma Scale Score 8 or Less 
Background
Airway management remains a fundamental component of optimal care of the severely injured patient, with endotracheal intubation representing the definitive strategy for airway control. However, multiple studies document an association between early intubation and increased mortality.
Objectives
To explore the relationship between intubation attempts and outcome across sites participating in the Resuscitation Outcomes Consortium (ROC).
Methods
The ROC Epistry – Trauma, an epidemiologic database of prehospital encounters with critically injured trauma victims, was used to identify EMS-treated patients with Glasgow Coma Scale (GCS) score ≤ 8. Multiple logistic regression was used to explore the association between intubation attempts and vital status at discharge adjusting for the following covariates: age, gender, GCS score, hypotension, mechanism of injury, and ROC site. Sites were then stratified by frequency of intubation attempts and chi-square test for trend used to associate the frequency of intubation attempts with outcome.
Results
1,555 patients were included in this analysis; intubation was attempted in 758 (49%) of these. Patients in whom intubation was attempted had higher mortality (adjusted odds ratio 2.91, 95% CI 2.13–3.98, p<0.01). However, sites with higher rates of attempted intubation had lower mortality across all trauma victims with GCS ≤ 8 (OR 1.40, 95% CI 1.15–1.72, p<0.01).
Conclusions
Patients in whom intubation is attempted have higher adjusted mortality. However, sites with a higher rate of attempted intubation have lower adjusted mortality across the entire cohort of trauma patients with GCS ≤ 8.
doi:10.3109/10903127.2010.545473
PMCID: PMC4091894  PMID: 21309705
prehospital intubation; traumatic brain injury; airway management; paramedic; outcomes; major trauma victim; ventilation
12.  The difficult airway in the emergency department 
Background
The patient with difficult airways is a common challenge for emergency physicians.
Aims
Our goal was to study the reasons for difficult airways in the emergency department.
Methods
We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.
Results
There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.
Conclusions
Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.
doi:10.1007/s12245-008-0030-6
PMCID: PMC2657243  PMID: 19384660
Airway; Intubation; Laryngoscopy; Cricothyroidotomy; Tracheostomy
13.  Tracheal intubation in the emergency department: the Scottish district hospital perspective 
Emergency Medicine Journal : EMJ  2007;24(6):394-397.
Background
Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs.
Objective
To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006.
Setting
Crosshouse Hospital, a 450‐bed district general hospital serving a mixed urban and rural population; annual ED census 58 000 patients.
Methods
Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid‐sequence induction (RSI) was defined as the co‐administration of an induction agent and suxamethonium.
Results
234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non‐RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties.
Conclusions
Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.
doi:10.1136/emj.2006.041988
PMCID: PMC2658270  PMID: 17513533
14.  How do paramedics manage the airway during out of hospital cardiac arrest? 
Resuscitation  2014;85(12):1662-1666.
Aim
The best method of initial airway management during resuscitation for out of hospital cardiac arrest (OHCA) is unknown. The airway management techniques used currently by UK paramedics during resuscitation for OHCA are not well documented. This study describes the airway management techniques used in the usual practice arm of the REVIVE-Airways feasibility study, and documents the pathway of interventions to secure and sustain ventilation during OHCA.
Method
Data were collected from OHCAs attended by paramedics participating in the REVIVE-Airways trial between March 2012 and February 2013. Patients were included if they were enrolled in the usual practice arm of the study, fulfilled the main study eligibility criteria and did not receive either of the intervention supraglottic airway devices during the resuscitation attempt.
Results
Data from 196 attempted resuscitations were included in the analysis. The initial approach to airway management was bag-mask for 108 (55%), a supraglottic airway device (SAD) for 39 (20%) and tracheal intubation for 49 (25%). Paramedics made further airway interventions in 64% of resuscitations. When intubation was the initial approach, there was no further intervention in 76% of cases; this compares to 16% and 44% with bag-mask and SAD respectively. The most common reason cited by paramedics for changing from bag-mask was to carry out advanced life support, followed by regurgitation and inadequate ventilation. Inadequate ventilation was the commonest reason cited for removing a SAD.
Conclusion
Paramedics use a range of techniques to manage the airway during OHCA, and as the resuscitation evolves. It is therefore desirable to ensure that a range of techniques and equipment, supported by effective training, are available to paramedics who attend OHCA.
doi:10.1016/j.resuscitation.2014.09.008
PMCID: PMC4265730  PMID: 25260723
Heart arrest; airway management; intubation, endotracheal; laryngeal masks.
15.  Preparation of the patient and the airway for awake intubation 
Indian Journal of Anaesthesia  2011;55(5):442-447.
Awake intubation is usually performed electively in the presence of a difficult airway. A detailed airway examination is time-consuming and often not feasible in an emergency. A simple 1-2-3 rule for airway examination allows one to identify potential airway difficulty within a minute. A more detailed airway examination can give a better idea about the exact nature of difficulty and the course of action to be taken to overcome it. When faced with an anticipated difficult airway, the anaesthesiologist needs to consider securing the airway in an awake state without the use of anaesthetic agents or muscle relaxants. As this can be highly discomforting to the patient, time and effort must be spent to prepare such patients both psychologically and pharmacologically for awake intubation. Psychological preparation is best initiated by an anaesthesiologist who explains the procedure in simple language. Sedative medications can be titrated to achieve patient comfort without compromising airway patency. Additional pharmacological preparation includes anaesthetising the airway through topical application of local anaesthetics and appropriate nerve blocks. When faced with a difficult airway, one should call for the difficult airway cart as well as for help from colleagues who have interest and expertise in airway management. Preoxygenation and monitoring during awake intubation is important. Anxious patients with a difficult airway may need to be intubated under general anaesthesia without muscle relaxants. Proper psychological and pharmacological preparation of the patient by an empathetic anaesthesiologist can go a long way in making awake intubation acceptable for all concerned.
doi:10.4103/0019-5049.89863
PMCID: PMC3237141  PMID: 22174458
Awake intubation; monitoring; pharmacological preparation; psychological preparation; topical anaesthesia
16.  Comparison of combitube, easy tube and tracheal tube for general anesthesia 
Background & Aims:
The Combitube® and EasyTube™ enable effective ventilation whether placed in the trachea or esophagus and can be used in prehospital settings, as well as in “Cannot Ventilate Cannot Intubate” situations in the operating room. Whether they can be continued to provide general anesthesia, if required, is not established. Thus the efficacy of Combitube and EasyTube was evaluated and compared with the tracheal tube for general anesthesia using controlled ventilation.
Materials and Methods:
Combitube, EasyTube and tracheal tubes were used in 30 patients each to secure the airway in a randomized controlled manner. Ventilatory parameters were measured along with hemodynamic variables, and characteristics related to device placement.
Results:
There was no significant difference in the various ventilatory parameters including minute ventilation requirement to maintain eucapnia amongst the three groups at any time point. There was no hypoxia or hypercarbia in any patient at any time. Placement of EasyTube was more difficult (P = 0.01) as compared with both Combitube and tracheal tube. EasyTube and Combitube resulted in higher incidence of minor trauma than with a tracheal tube (P = 0.00).
Conclusion:
Combitube and EasyTube may be continued for general anesthesia in patients undergoing elective nonlaparoscopic surgeries of moderate duration, if placed for airway maintenance. Given the secondary observations regarding placement characteristics of the airway devices, it, however cannot be concluded that the devices are a substitute for endotracheal tube for airway maintenance per se, unless specifically indicated
doi:10.4103/0970-9185.142849
PMCID: PMC4234790  PMID: 25425779
Combitube; EasyTube; general anesthesia
17.  Assessment of Truflex™ articulating stylet versus conventional rigid Portex™ stylet as an intubation guide with the D-blade of C-Mac™ videolaryngoscope during elective tracheal intubation: study protocol for a randomized controlled trial 
Trials  2013;14:298.
Background
A variety of videolaryngoscopes with angulated blade have been recently introduced into clinical practice. They provide an indirect view of the glottic structures in normal and challenging clinical settings. Despite the very good visualization of the laryngeal structures by these devices, the insertion and advancement of the endotracheal tube may be prolonged and occasionally fail as it does not conform to the enhanced angulation of the blade. To overcome this handicap, it is recommended to use a pre-shaped, styleted tracheal tube during intubation. Unfortunately, these malleable rigid stylets permit only a fixed shape to the advancing endotracheal tube. This may necessitate withdrawal of endotracheal tube-stylet assembly for reshaping, before undertaking a new attempt. This may cause soft tissue injury and hemodynamic disturbance.
This single-blinded randomized clinical trial aims to overcome these handicaps using a novel method of dynamically changing the shape of the advancing endotracheal tube by Truflex™ articulating stylet as per need during D-blade C-Mac™ videolaryngoscopy.
Methods
One hundred and fifty four patients between 18 and 60 years of age belonging to either sex undergoing tracheal intubation under uniform general anesthetic technique will be randomly divided into Portex™ malleable stylet group and Truflex™ articulating stylet group. The primary efficacy variable of success/failure between the two groups will be analyzed using the chi square test. For comparison of intubation times and the Intubation Difficulty Score, ANOVA will be used. Primary efficacy endpoint results will be successful or failed tracheal intubation in the first attempt, total intubation time and the intubation difficulty score. Secondary efficacy endpoints will be overall user satisfaction graded from 1 to 10 (1 = very poor, 10 = excellent), Cormack and Lehane’s grading, glotticoscopy time and ETT negotiation time and total number of intubation attempts. Result of safety endpoints will include dental and airway trauma, hemodynamic disturbances, arrhythmias or cardiac arrest.
Trial registration
Current Controlled Trials ISRCTN57679531; Date of registration 12/02/2013
doi:10.1186/1745-6215-14-298
PMCID: PMC3848553  PMID: 24041300
Videolaryngoscope; Tracheal intubation; Truflex stylet
18.  Delayed Complications of Emergency Airway Management: A Study of 533 Emergency Department Intubations 
Objectives
Airway management is a critical procedure performed frequently in emergency departments (EDs). Previous studies have evaluated the complications associated with this procedure but have focused only on the immediate complications. The purpose of this study is to determine the incidence and nature of delayed complications of tracheal intubation performed in the ED at an academic center where intubations are performed by emergency physicians (EPs).
Methods
All tracheal intubations performed in the ED over a one-year period were identified; 540 tracheal intubations were performed during the study period. Of these, 523 charts (96.9%) were available for review and were retrospectively examined. Using a structured datasheet, delayed complications occurring within seven days of intubation were abstracted from the medical record. Charts were scrutinized for the following complications: acute myocardial infarction (MI), stroke, airway trauma from the intubation, and new respiratory infections. An additional 30 consecutive intubations were examined for the same complications in a prospective arm over a 29-day period.
Results
The overall success rate for tracheal intubation in the entire study group was 99.3% (549/553). Three patients who could not be orally intubated underwent emergent cricothyrotomy. Thus, the airway was successfully secured in 99.8% (552/553) of the patients requiring intubation. One patient, a seven-month-old infant, had unanticipated subglottic stenosis and could not be intubated by the emergency medicine attending or the anesthesiology attending. The patient was mask ventilated and was transported to the operating room for an emergent tracheotomy. Thirty-four patients (6.2% [95% CI 4.3 – 8.5%]) developed a new respiratory infection within seven days of intubation. Only 18 patients (3.3% [95% CI 1.9 – 5.1%]) had evidence of a new respiratory infection within 48 hours, indicating possible aspiration pneumonia secondary to airway management. Three patients (0.5% [95% CI 0.1 – 1.6%]) suffered an acute MI, but none appeared to be related to the intubation. One patient was having an acute MI at the time of intubation and the other two patients had MIs more than 24 hours after the intubation. No patient suffered a stroke (0% [95% CI 0 – 0.6%]). No patients suffered any serious airway trauma such as a laryngeal or vocal cord injury.
Conclusions
Emergency tracheal intubation in the ED is associated with an extremely high success rate and a very low rate of delayed complications. Complication rates identified in this study compare favorably to reports of emergency intubations in other hospital settings. Tracheal intubation can safely be performed by trained EPs.
PMCID: PMC2672279  PMID: 19561743
19.  Variation in the Type, Rate, and Selection of Patients for Out-of-hospital Airway Procedures Among Injured Children and Adults 
Objectives
The objective was to compare the type, rate, and selection of injured patients for out-of-hospital airway procedures among emergency medical services (EMS) agencies in 10 sites across North America.
Methods
The authors analyzed a consecutive patient, prospective cohort registry of injured adults and children with an out-of-hospital advanced airway attempt, collected from December 1, 2005, through February 28, 2007, by 181 EMS agencies in 10 sites across the United States and Canada. Advanced airway procedures were defined as orotracheal intubation, nasotracheal intubation, supraglottic airway, or cricothyrotomy. Airway procedure rates were calculated based on age-specific population values for the 10 sites and the number of injured patients with field physiologic abnormality (systolic blood pressure of ≤90 mm Hg, respiratory rate of <10 or >29 breaths / min, Glasgow Coma Scale [GCS] score of ≤12). Descriptive measures were used to compare patients between sites.
Results
A total 1,738 patients had at least one advanced airway attempt and were included in the analysis. There was wide variation between sites in the types of airway procedures performed, including orotracheal intubation (63% to 99%), supraglottic airways (0 to 27%), nasotracheal intubation (0 to 21%), and cricothyrotomy (0 to 2%). Use of rapid sequence intubation (RSI) varied from 0% to 65%. The population-adjusted rates of field airway intervention (by site) ranged from 1.2 to 22.8 per 100,000 adults and 0.2 to 4.0 per 100,000 children. Among trauma patients with physiologic abnormality, some sites performed airway procedures in almost 50% of patients, while other sites used these procedures in fewer than 10%. There was also large variation in demographic characteristics, physiologic measures, mechanism of injury, mode of transport, field cardiopulmonary resuscitation, and unadjusted mortality among airway patients.
Conclusions
Among 10 sites across North America, there was wide variation in the types of out-of-hospital airway procedures performed, population-based rates of airway intervention, and the selection of injured patients for such procedures.
doi:10.1111/j.1553-2712.2009.00604.x
PMCID: PMC3954116  PMID: 20053248
trauma; emergency medical services; out-of-hospital; airway; intubation; epidemiology
20.  EMS-physicians' self reported airway management training and expertise; a descriptive study from the Central Region of Denmark 
Background
Prehospital advanced airway management, including prehospital endotracheal intubation is challenging and recent papers have addressed the need for proper training, skill maintenance and quality control for emergency medical service personnel. The aim of this study was to provide data regarding airway management-training and expertise from the regional physician-staffed emergency medical service (EMS).
Methods
The EMS in this part of The Central Region of Denmark is a two tiered system. The second tier comprises physician staffed Mobile Emergency Care Units. The medical directors of the programs supplied system data. A questionnaire addressing airway management experience, training and knowledge was sent to the EMS-physicians.
Results
There are no specific guidelines, standard operating procedures or standardised program for obtaining and maintaining skills regarding prehospital advanced airway management in the schemes covered by this study. 53/67 physicians responded; 98,1% were specialists in anesthesiology, with an average of 17,6 years of experience in anesthesiology, and 7,2 years experience as EMS-physicians. 84,9% reported having attended life support course(s), 64,2% an advanced airway management course. 24,5% fulfilled the curriculum suggested for Danish EMS physicians. 47,2% had encountered a difficult or impossible PHETI, most commonly in a patient in cardiac arrest or a trauma patient. Only 20,8% of the physicians were completely familiar with what back-up devices were available for airway management.
Conclusions
In this, the first Danish study of prehospital advanced airway management, we found a high degree of experience, education and training among the EMS-physicians, but their equipment awareness was limited. Check-outs, guidelines, standard operating procedures and other quality control measures may be needed.
doi:10.1186/1757-7241-19-10
PMCID: PMC3045910  PMID: 21303510
21.  Real-Time Subglottic Stenosis Imaging Using Optical Coherence Tomography in the Rabbit 
Importance
Subglottic stenosis (SGS) is a severe, acquired, potentially life-threatening disease that can be caused by endotracheal tube intubation. Newborns and neonates are particularly susceptible to SGS owing to the small caliber of their airway.
Objective
To demonstrate optical coherence tomography (OCT) capabilities in detecting injury and scar formation using a rabbit model. Optical coherence tomography may provide a noninvasive, bedside or intensive care unit modality for the identification of early airway trauma with the intention of preventing progression to SGS and can image the upper airway through an existing endotracheal tube coupled with a small fiber-optic probe.
Design
Rabbits underwent suspension laryngoscopy with induction of of SGS via epithelial injury. This model was used to test and develop our advanced, high-speed, high-resolution OCT imaging system using a 3-dimensional microelectromechanical systems-based scanning device integrated with a fiber-optic probe to acquire high-resolution anatomic images of the subglottic epithelium and lamina propria.
Setting
All experiments were performed at the Beckman Laser Institute animal operating room.
Intervention or Exposure
Optical coherence tomography and endoscopy was performed with suspension laryngoscopy at 6 different time intervals and compared with conventional digital endoscopic images and histologic sections. Fifteen rabbits were killed at 3, 7, 14, 21, and 42 days after the induction of SGS. The laryngotracheal complexes were serially sectioned for histologic analysis.
Main Outcome and Measure
Histologic sections, endoscopic images, and OCT images were compared with one another to determine if OCT could accurately delineate the degree of SGS achieved.
Results
The rabbit model was able to reliably and reproducibly achieve grade I SGS. The real-time OCT imaging system was able to (1) identify multiple structures in the airway; (2) delineate different tissue planes, such as the epithelium, basement membrane, lamina propria, and cartilage; and (3) detect changes in each tissue plane produced by trauma. Optical coherence tomography was also able demonstrate a clear picture of airway injury that correlated with the endoscopic and histologic images. With subjective review, 3 patients had high correlation between OCT and histologic images, 10 demonstrated some correlation with histologic images, and 2 showed little to no correlation with histologic images.
Conclusions and Relevance
Optical coherence tomography, coupled with a fiber-optic probe, identifies subglottic scarring and can detect tissue changes in the rabbit airway to a depth of 1 mm. This technology brings us 1 step closer to minimally invasive subglottic airway monitoring in the intubated neonate, with the ultimate goal of preventing SGS and better managing the airway.
doi:10.1001/jamaoto.2013.2643
PMCID: PMC3893145  PMID: 23681033
22.  Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country – a prospective study 
Background
An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving.Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.
Methods
The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy.
All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version.
The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant.
Results
At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score.
The average day of tracheostomy was 2.18 ± 1.0038 days.
The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group.Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury
Conclusion
It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.
doi:10.1186/1471-227X-5-8
PMCID: PMC1266359  PMID: 16236181
23.  Rigid fibrescope Bonfils: use in simulated difficult airway by novices 
Background
The Bonfils intubation fibrescope is a promising alternative device for securing the airway. We examined the success rate of intubation and the ease of use in standardized simulated difficult airway scenarios by physicians. We compared the Bonfils to a classical laryngoscope with Macintosh blade.
Methods
30 physicians untrained in the use of rigid fibrescopes but experienced in airway management performed endotracheal intubation in an airway manikin (SimMan, Laerdal, Kent, UK) with three different airway conditions. We evaluated the success rate using the Bonfils (Karl Storz, Tuttlingen, Germany) or the Macintosh laryngoscope, the time needed for securing the airway, and subjective rating of both techniques.
Results
In normal airway all intubations were successful using laryngoscope (100%) vs. 82% using the Bonfils (p < 0.05). In the scenario "tongue oedema" success rate using the Macintosh laryngoscope was 67% and 83% using the Bonfils. In the scenario "decreased cervical range of motion with jaw trismus", success rate using the Macintosh laryngoscope was 84% vs. 76%. In difficult airway scenarios time until airway was secured did not differ between the two devices. Use of Bonfils was rated "easier" in both difficult airway scenarios.
Conclusion
The Bonfils can be successfully used by physicians unfamiliar with this technique in an airway manikin. The airway could be secured with at least the same success rate as using a Macintosh laryngoscope in difficult airway scenarios. Use of the Bonfils did not delay intubation in the presence of a difficult airway. These results indicate that intensive special training is advised to use the Bonfils effectively in airway management.
doi:10.1186/1757-7241-17-33
PMCID: PMC2718855  PMID: 19624837
24.  Critical care considerations in the management of the trauma patient following initial resuscitation 
Background
Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented.
Methods
A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012.
Results and conclusion
Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.
doi:10.1186/1757-7241-20-68
PMCID: PMC3566961  PMID: 22989116
Coagulopathy; Trauma; Acute lung injury; Transfusion; Intensive care unit; Complications; Thromboelastography
25.  The performance and assessment of hospital trauma teams 
The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff.
Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.
doi:10.1186/1757-7241-18-66
PMCID: PMC3017008  PMID: 21144035

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