Peri-intubation Cardiovascular Collapse During Emergency Airway Management.

Of late there has been a debate on whether green revolution has reduced absolute poverty among farm families in India. Most of the studies examining the issue relate to the all-India rural sector. But since the green revolution has not spread evenly in all the regions, the changes in the level of poverty reported in these istudies do not strictly relate to the phenomenon. Haryana is one of those few regions where new agricultural technology has spread more widely than others and therefore the experience of its farmers should provide us a better picture of how poverty among farmers changes with the spread of new farming technology.

Resuscitation highlights in 2013: Part 2

Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

Rapid sequence induction (RSI) for endotracheal intubation is a technique widely used in anaesthesia, emergency and intensive care medicine to secure an airway in patients deemed at risk of pulmonary aspiration. Cricoid pressure is conceptually used to reduce the risk of aspiration by compressing the oesophagus. To identify and evaluate all randomized controlled trials (RCTs) involving participants undergoing elective or emergency airway management via RSI and compare participants who have cricoid pressure administered with participants who do not have cricoid pressure administered. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 4), MEDLINE via OvidSP (1946 to May 2015), EMBASE via OvidSP (1980 to May 2015), ISI Web of Science (from 1940 to May 2015) and CINAHL via EBSCOhost (1982 to May 2015). We included all RCTs comparing people undergoing RSI who have cricoid pressure applied, either intermittently or continuously, with people undergoing RSI who do not have cricoid pressure applied in the context of endotracheal intubation using a direct laryngoscopic technique. We included both elective and emergency cases. We included studies of blinded and unblinded participants. Participants (male or female) were involved in any type of procedure where general anaesthetic utilizing RSI or emergency airway management utilizing RSI and endotracheal intubation was undertaken. We expected the control arm to be the absence of cricoid pressure at any stage during RSI. The primary outcome of interest was the reported event rate or prevalence of aspiration determined by a) documented gastric aspiration determined by visual inspection of aspirated stomach contents on laryngoscopy; b) pepsin detection in tracheal aspirate using the Ufberg method; c) post-anaesthetic radiographic changes suggestive of aspiration pneumonitis or d) any combination of a to c. Secondary outcomes of interest included documented impaired visualization of the airway by a treating laryngoscopist, force applied during cricoid pressure, the direction of application of force of applied cricoid pressure, independent risk factors for aspiration and whether the person applying cricoid pressure had previously done so in an emergency airway context. Two review authors independently screened the titles and abstracts of all the studies obtained from the search using recognition of words such as 'cricoid pressure', 'rapid sequence intubation', 'emergency airway management' and 'aspiration'. Two authors independently determined the study inclusion by using a study eligibility form that we developed for the purpose of this review. We also reported the decisions regarding inclusion and exclusion in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. We assumed that studies that did not describe the use of RSI in their title, abstract or methodology used an alternative method of anaesthetic induction or emergency airway management and thus we excluded them. Data extracted from included studies comprised study characteristics, participant demographics, intervention and comparison details plus outcome measures and results. We contacted primary authors of studies with missing or unreported but potentially relevant data to obtain missing data. Of 493 records that we identified from databases as a result of the search (excluding duplicates), we regarded 70 abstracts/titles as potentially relevant studies. Independent scrutiny of these 70 titles and abstracts identified 29 potentially relevant studies. Of the 29 potentially relevant studies, one study met the criteria for inclusion. This study was a RCT that compared participants undergoing RSI and endotracheal intubation in the context of elective surgery requiring a general anaesthetic. Forty participants were recruited, 20 of whom had cricoid pressure applied and 20 of whom had cricoid pressure simulated. The main outcomes reported were systolic arterial pressure and heart rate after laryngoscopy and tracheal intubation. We did not consider these outcomes relevant for the purposes of this systematic review. The search also identified one study that could potentially be included in an updated systematic review in the future, but was at the time of the search a proposal for a trial only and had no reported outcomes at this time. There is currently no information available from published RCTs on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI in the context of endotracheal intubation. On the basis of the findings of non-RCT literature, however, cricoid pressure may not be necessary to undertake RSI safely, and therefore well-designed and conducted RCTs should nonetheless be encouraged to properly assess the safety and effectiveness of cricoid pressure.

Editorial IV: Airway management in the emergency department

Emergency physicians: additional providers of emergency anaesthesia?

Use of ECMO in Patients With Coronavirus Disease 2019: Does the Evidence Suffice?

Emergency airway management in penetrating neck injury

Point: Should an Anesthesiologist Be the Specialist of Choice in Managing the Difficult Airway in the ICU? Yes

Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: 1) preintubation assessment for potential difficulty (e.g., MACOCHA score); 2) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and 3) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.

Emergency airway management is one of the most important resuscitative procedures performed in the emergency room (ED). Despite the clinical and research importance of intubation in the management of critically ill and injured patients, previous studies have reported inadequate intubation performance and significant adverse event rates, with wide variation amongst emergency departments (EDs). Emergency airway management in the ED can be difficult for the emergency physician due to multiple ED-specific factors, such as vomiting, facial/neck trauma, immobilised cervical spine, and chest compressions for resuscitation, which influence intubation success and failure. To accomplish timely and successful intubation of these ED patients at high risk, it is crucial to comprehend the current evidence on emergency airway management. This chapter discusses the airway management processes, including evaluation of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devices), and rescue intubation strategies (e.g., airway adjuncts and rescue in (i.e., trauma, cardiac arrest, and paediatric patients).

We must not sacrifice anaesthesia rotations as part of emergency medicine training.

Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department

Rapid sequence induction-intubation (RSII) is ‘the standard of care’ practice since decades while anaesthetising a full stomach patient or during emergency airway management. Cricoid pressure (CP), an important manoeuvre, labelled as the ‘linchpin of rapid sequence induction-intubation’, when not performed properly can lead to catastrophic results. The purpose of this review of literature is to discuss if rapid sequence induction and application of cricoid pressure is a safe and effective technique in managing a full stomach patient. Literature from multiple sources was searched for key words, subject headings and text entries on rapid sequence induction, rapid sequence induction and intubation, and cricoid pressure. Outcomes such as prevention of aspiration and prevention of other airway complications such as airway trauma could not be evaluated based on the literature available at present. There is lack of clear cut evidence from randomised controlled trials on the safety and effectiveness of rapid sequence induction-intubation and cricoid pressure. Despite wide acceptance of RSII, its role in emergency airway management is still debated. CP as an essential skill, lacks in its uniformity among clinicians, technicians and nurses, and simulation based training hold promise in this regard.

Rapid sequence intubation (RSI) is a critical procedure in emergency airway management, requiring rapid induction of unconsciousness and muscle relaxation to facilitate safe intubation. The choice of induction agent plays a pivotal role in optimizing outcomes, as each agent exhibits unique pharmacokinetic and pharmacodynamic profiles. Etomidate is frequently chosen for its hemodynamic stability, making it suitable for critically ill patients; however, concerns regarding adrenal suppression warrant caution in septic or prolonged critical illness cases. Ketamine is particularly advantageous in patients with reactive airway diseases or hypotension, owing to its bronchodilatory effects and ability to preserve respiratory drive, although its psychotomimetic side effects must be managed carefully. Propofol, characterized by its rapid onset and short duration, provides excellent intubating conditions but may cause significant hypotension, limiting its use in hemodynamically unstable patients. Thiopental, once widely used, is now less favored due to cardiovascular depression and prolonged recovery times. Patient-specific factors, including age, comorbidities, and clinical status, heavily influence agent selection. Pediatric and geriatric populations pose unique challenges, necessitating dose adjustments and close monitoring. Emerging agents like dexmedetomidine offer novel benefits such as sedation with preserved respiratory function, though slower onset limits its utility in emergency settings. The complexity of decision-making underscores the importance of understanding the nuances of each agent’s efficacy and safety. Despite advancements in pharmacological options, limitations in evidence, variability in patient responses, and resource constraints highlight the need for individualized approaches and adaptable guidelines. Further research is essential to bridge gaps in knowledge and establish standardized practices to enhance safety and effectiveness in RSI across diverse clinical scenarios.