Emergency Airway Research Articles

Quality Improvement of Pediatric Airway Emergency Carts: Standardization, Streamlining, and Simulation.

Objective Pediatric airway emergencies are amongst the most tenuous scenarios faced byon-call providers, requiring quick access to the appropriate equipment and a timely response. In the present study, we report on the testing and improvement ofpediatric airway carts at our institution. The primary objective was to optimize our pediatric airway emergency carts to improve response times. Secondarily, we aimed to implement a training scenario to improve providers' familiarity and confidence in attaining and assembling equipment. Methods Surveys of airway cart configuration at our hospital and others were used to identify differences. Volunteer otolaryngology physicians were tasked with responding to a mock scenario using an existing cart or one modified based on the survey. Outcomes included (1) time to arrival of the provider with the appropriate equipment, (2) time from arrival to complete assembly of equipment, and (3) time for re-assembly of the equipment. Results The survey revealed differences in cart equipment and location. The inclusion of a flexible bronchoscope and a video tower, as well as the placement of the carts directly within the ICU, resulted in improved time to arrival by an average of 181 seconds, and improved equipment assembly time by an average of 85 seconds. Discussion Standardization of pediatric airway equipment on the cart and location near critically ill patients improved response efficiency. Simulation led to improved confidence and reduced reaction time among providers at all levels of experience. Conclusion The present study provides an example for the optimization of airway carts, which can be adapted by healthcare systems to their local milieu.

Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present aliterature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine. Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors. The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have agastric drainage possibility. Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of alocal emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

A Practical Solution for Preoxygenation in the Prehospital Setting: A Nonrebreather Mask with Flush Rate Oxygen

Objective Prehospital clinicians need a practical means of providing adequate preoxygenation prior to intubation. A bag-valve-mask (BVM) can be used for preoxygenation in perfect conditions but is likely to fail in emergency settings. For this reason, many airway experts have moved away from using BVM for preoxygenation and instead suggest using a nonrebreather (NRB) mask with flush rate oxygen. Literature on preoxygenation has suggested that a NRB mask delivering flush rate oxygen (on a 15 L/min O2 regulator, maximum flow, ∼50 L/min) is noninferior to BVM at 15 L/min held with a tight seal. However, in the prehospital setting, where emergency airway management success varies, preoxygenation techniques have not been deeply explored. Our study seeks to determine whether preoxygenation can be optimally performed with NRB at flush rate oxygen. Methods We performed a crossover trial using healthy volunteers. Subjects underwent 3-min trials of preoxygenation with NRB mask at 25 L/min oxygen delivered from a portable tank, NRB at flush rate oxygen from a portable tank, NRB with flush rate oxygen from an onboard ambulance tank, and BVM with flush rate oxygen from an onboard ambulance tank. The primary outcome was the fraction of expired oxygen (FeO2). We compared the FeO2 of the BVM-flush to other study groups, using a noninferiority margin of 10%. Results We enrolled 30 subjects. Mean FeO2 values for NRB-25, NRB-flush ambulance, NRB-flush portable, and BVM-flush were 63% (95% confidence interval [CI] 58–68%), 74% (95%, CI 70–78%), 78% (95%, CI 74–83%), and 80% (95%, CI 75–84%), respectively. FeO2 values for NRB-flush on both portable tank and ambulance oxygen were noninferior to BVM-flush on the ambulance oxygen system (FeO2 differences of 1%, 95% CI −3% to 6%; and 6%, 95% CI 1–10%). FeO2 for the NRB-25 group was inferior to BVM-flush (FeO2 difference 16%, 95% CI 12–21%). Conclusions Among healthy volunteers, flush rate preoxygenation using NRB masks is noninferior to BVM using either a portable oxygen tank or ambulance oxygen. This is significant because preoxygenation using NRB masks with flush rate oxygen presents a simpler alternative to the use of BVMs. Preoxygenation using NRB masks at 25 L/min from a portable tank is inferior to BVM at flush rate.

Acute airway obstruction requiring nasotracheal intubation following hypoglossal neuromonitoring: a case report

BackgroundIntraoperative neurophysiological monitoring (IONM) is utilized for both the localization of critical structures and for real time detection and prevention of intraoperative neurological injury. Use of IONM to monitor the hypoglossal nerve is performed during neurosurgical, otolaryngological, and vascular procedures to improve surgical outcomes. There is a paucity of literature describing potential complications of IONM of the hypoglossal nerve, especially with respect to airway compromise. Here we present our findings regarding a case of acute airway obstruction following hypoglossal nerve monitoring.Case PresentationA 54-year-old male was admitted for left far-lateral craniotomy and microsurgical clipping of a left posterior inferior cerebellar artery (PICA) aneurysm. Following induction and intubation but prior to the procedure start, the patient was placed in the ¾ prone position with the left side up and his neck was flexed approximately 10 degrees. He then underwent placement of subdermal needle electrodes into the facial muscles, trapezius muscles, soft palate, and tongue for IONM. The procedure lasted 523 minutes and was completed without complication. However, approximately one hour after emergence from general anesthesia, the patient experienced progressive difficulty breathing secondary to severe lingual swelling. He required emergent placement of a nasotracheal tube guided by a fiberoptic bronchoscope. He remained intubated for 3 days and was treated with dexamethasone, after which the swelling resolved, and the patient was successfully extubated.ConclusionsAcute lingual edema is a potentially life-threatening phenomenon that can lead to rapid airway compromise. Generally, causes of acute lingual swelling include hemorrhage, edema, infarction, and infection. In the case described above, we suspect traumatic injury to the tongue’s vascular supply caused a deep tissue hematoma leading to postoperative acute lingual swelling and airway obstruction. With the widespread use of IONM, it becomes essential for providers to be aware that perioperative airway compromise is a potentially life-threatening complication, especially with respect to monitoring of the hypoglossal nerve. Awake fiberoptic nasotracheal intubation can successfully be employed to establish an emergency airway in such situations.

Difficult Airway Response Team (DART) and Airway Emergency Outcomes: A Retrospective Quality Improvement Study.

Difficult airways can be associated with significant morbidity and mortality, particularly in the event of a delay in securing the airway. To improve the airway metrics at our institution, we implemented a multidisciplinary team of airway providers to respond to difficult and emergent airways, or the Difficult Airway Response Team (DART). The purpose of the present study is to assess the feasibility of a DART program at a tertiary care center. A retrospective study evaluating the outcomes of emergent airway cases using the DART protocol. Single tertiary academic care center. In August 2019, a DART program was implemented at a tertiary academic medical center. In order to assess the feasibility and effectiveness of this system, data were collected to assess DART outcomes through chart review and surveys following each event, and analyzed in Microsoft Excel. A total of 161 DART events (average 4.6/month) took place from August 2019 to June 2022. Anesthesiologists secured the airway in 71 events (51%), otolaryngologists in 38 (27%), and pulmonary/critical care in 12 (9%). Seventy-three activations were not labeled as a difficult airway. Pre-DART, 19 cases required more than 3 attempts to secure the airway compared to 11 cases after DART. Transoral intubation was the most common intervention. Thirteen cases required surgical intervention. Implementing a multidisciplinary team-based approach for managing emergent difficult airways at a tertiary care institution was feasible and resulted in a decreased number of airway attempts in difficult airway patients. Continuous process improvement is essential for the ongoing enhancement of DART systems.

A Blended Learning Approach to Emergency Airway Training in a Low Resource Environment

Introduction:Global Emergency Care Skills (GECS) is a charity which delivers medical training to health care professionals in low and middle income countries. Teaching airway management both didactically and through simulation training is a key component of the GECS Emergencies and Trauma Course. In 2022, a team of doctors delivered an intensive, five-day teaching course with a strong emphasis on airway management and airway emergencies at St. Joseph’s Nyabondo Mission Hospital in rural Kenya. This course was delivered to a group of doctors, nurses and clinical officers. At the conclusion of this course we collected qualitative feedback from course participants. The aim of this study was to assess airway knowledge and skills acquisition, as well as real-world application and potential for ongoing teaching of acquired airway skills.Method:A questionnaire was distributed to course participants to ascertain their experience of didactic airway teaching, airway skills stations, and airway simulation. Each question offered a binary response. To continue to enhance course content, we invited participants to submit qualitative feedback at the end of the questionnaire.Results:Questionnaires were returned by 19 of a total 24 participants. 53% were registered nurses, 21% were clinical officers, 5% were medical officers and 21% did not respond to this question. Median post graduate clinical experience was four years (2.75-5.25). 37% indicated that they had not heard of simulation training for medical education before undertaking this course. 58% had no previous airway training although 63% had prior exposure to clinical situations which required emergency airway management. 100% reported feeling more confident in their airway skills and potential for training colleagues following this course.Conclusion:The results indicate that participants gained knowledge, skills, and confidence when approaching airway emergencies. Furthermore, results showed increased perceived competence by participants at providing airway training to colleagues.

Using cognitive load theory to develop an emergency airway management curriculum: the Queen's University Mastery Airway Course (QUMAC).

Emergency airway management requires the simultaneous coordination of clinical reasoning and therapeutic interventions in the complex and time-sensitive setting of emergency resuscitation. The cognitive demand associated with these situations is invariably high and must be taken into consideration when designing training programs for this core professional competency. The four-component instructional design model (4C/ID), based on cognitive load theory, was used to develop a 1-year longitudinal airway management curriculum for Emergency Medicine residents. The simulation-based curriculum was designed with the goal of facilitating the construction and automation of schemas by individual residents in preparation for the high cognitive demand associated with emergency airway management in the clinical environment.

頸髄損傷に合併した経鼻胃管症候群の1例(A case of nasogastric tube syndrome with cervical spinal injury)

経鼻胃管症候群とは，経鼻胃管留置後に咽頭痛，両側声帯の外転麻痺，喉頭浮腫を発症する症候群である。両側声帯麻痺を認めれば気道緊急を要し，しばしば致命的となる。症例は46歳の男性。墜落外傷により当院搬送となった。精査の結果，外傷性くも膜下出血，第6・7頸椎・第6–10胸椎骨折，第6・7頸髄・第6–8胸髄損傷と診断し，入院加療を開始した。第2病日麻痺性イレウスを発症し，経鼻胃管を留置し，減圧加療を開始した。第11病日吸気性喘鳴を聴取し，酸素8L/分投与下でSpO2（経皮的酸素分圧）88%まで低下を認めた。喉頭ファイバースコピー検査で両側声帯麻痺を認め，気道緊急として経口気管挿管を施行し，人工呼吸管理を開始した。第14病日気管切開術を施行した。第39病日声帯麻痺の治癒を確認した。第45病日リハビリテーション目的に転院した。 Nasogastric tube syndrome presents as throat pain, bilateral abductor paralysis of the vocal cords and pharyngeal edema after nasogastric tube placement. This syndrome often requires emergency airway management due to bilateral abductor paralysis and thus can be fatal. A 46–year–old man was transported to the emergency room due to trauma from a fall. We diagnosed traumatic subarachnoid hemorrhage, cervical and thoracic spine fractures, and cervical and thoracic spinal cord injury, and admitted him. On hospital day 2, a nasogastric tube was inserted due to paralytic ileus. On day 11, wheezing was heard on exhalation, and his SpO2 decreased to 88% on oxygen at 8L/min. Laryngeal fiberscopy revealed bilateral vocal cord paralysis, so he was intubated orally. A tracheotomy was performed on day 14. The vocal cord paralysis had healed by day 39, and on day 45, he was transferred to another hospital for rehabilitation. 経鼻胃管症候群とは，経鼻胃管留置後に咽頭痛，両側声帯の外転麻痺，喉頭浮腫を発症する症候群である。両側声帯麻痺を認めれば緊急気道確保を要し，しばしば致命的となる。今回，頸髄損傷を背景として経鼻胃管留置中に両側声帯麻痺を発症した1例を経験したので報告する。 当論文は当院倫理委員会の承諾を受け，個人情報保護法に基づいて匿名化を行っている。また，患者およびその家族から論文の出版に関する同意を得ている。 患 者：49歳の男性。身長180cm，体重91.6kg，BMI 28.3 既往歴：統合失調症 内服薬：アリピプラゾール，フルニトラゼパム，ゾルピデム酒石塩酸，クエチアピンフマル酸塩，アムロジピンベシル酸塩 現病歴：自宅3階からの飛び降りによる転落外傷で受傷した。目撃者が救急要請し，当院救急搬送となった。 来院時現症：気道は開通，呼吸音 清，呼吸様式 正常，呼吸数16/分，SpO2 97%（酸素10L/分 投与下），血圧85/45mmHg，脈拍72/分，Glasgow coma scale E3V5M6，瞳孔径2mm/2mm，対光反射は両側迅速，体温36.2度（腋窩温）であった。 身体所見：後頭部に約20cmの裂創を認めるが活動性出血は認めなかった。右膝・両踵に擦過傷を認めた。徒手筋力テストは両上下肢いずれもMMT 3以上であるが，意思疎通がとれず，詳細な評価は困難であった。持続勃起や肛門括約筋の弛緩は認めなかった。 血液検査：WBC 17,300/µL（Neut 89.4%），Hb 16.4g/dL，Plt 34.9×104/mm3，PT–INR 1.17，Fibrinogen 180mg/dL，APTT 22.2秒，D–dimer 41.21µg/mL 動脈血液ガス分析（酸素マスク10L/分投与下）：pH 7.359，PaCO2 38.0mmHg，PaO2 148.1mmHg，HCO3− 20.9mmol/L，B.E. −4.0mmol/L，lactate 29.2mg/dL 全身CT画像検査：外傷性くも膜下出血，第6・7頸椎棘突起骨折，左第4・5肋骨骨折，第6–8・10胸椎椎体骨折を認めた。 来院時ショックの状態であり，神経原性ショックの可能性を念頭に置いて診療したが，輸液負荷のみで血圧は安定し，入院加療を開始した。血液検査でのWBCおよびD–dimerの上昇は外傷に起因するものと判断した。第2病日，腸蠕動音減弱および腹部レントゲン検査で小腸の拡張を認め，麻痺性イレウスと診断し，減圧目的に20Frの経鼻胃管を留置した。第3病日下肢の筋力低下の訴えがあり，頭部・頸椎・胸椎MRI撮像したところ，T2強調像で第6椎体前面および第6–7頸髄内，第6–8胸髄内の高信号を認め，第6–7頸髄損傷，第6–8胸髄損傷と診断した（Fig. 1）。頸椎カラー装着継続で保存加療の方針とした。リハビリテーション目的の転院調整を開始しようとしたが，第11病日突然の吸気性喘鳴を認め，ボスミン筋肉注射を行うも改善を認めなかった。喉頭ファイバースコピー検査で両側声帯麻痺と診断した（Fig. 2A）。次第にSpO2は低下し，酸素8L/分 投与下にSpO2 88%前後まで酸素化低下を認めた。その時点での動脈血液ガス分析では，pH 7.501，PaCO2 48.8mmHg，PaO2 67.9mmHg，HCO3− 37.3mmol/L，B.E. 12.5mmol/L，lactate 11.8mg/dLと低酸素血症，高二酸化炭素血症を呈していた。経口気管挿管による気道確保を行い，人工呼吸管理を開始した。その後は原因検索を行ったが器質的疾患はいずれも否定的で，経鼻胃管症候群と診断した。麻痺性イレウスは遷延しており，経鼻胃管の抜去は困難であったため，第13病日経鼻胃管を18Frに入れ替えた。長期の気管挿管となることが予想され，第14病日気管切開術を施行した。腸蠕動音正常，腹部レントゲン検査で小腸の拡張の改善を認め，麻痺性イレウスの治癒と判断し，第16病日栄養投与目的に経鼻胃管を10Frに入れ替えた。第39病日喉頭ファイバースコピー検査で声帯麻痺の治癒を確認した（Fig. 2B）。精神状態悪化による昏迷状態となっており，気管切開チューブはスピーチカニューレへの入れ替えにとどめた。第45病日頸椎カラーは装着を継続しリハビリテーション目的に転院した（injury severity score: 17，probability of survival: 0.97972であった）。 Magnetic resonance imaging of the cervical and thoracic vertebrae. MRI（T2）revealed spinal cord injury at the sixth and seventh cervical vertebrae and from the sixth to eighth thoracic vertebrae (red arrow), and 5–mm retropharyngeal hematoma (yellow arrow). Laryngeal fiberscopy. A: Laryngeal fiberscopy showed abnormal abducton of the vocal cords. (during the phase of expiration (left) / inspiration (right)) B: Laryngeal fiberscopy showed recovery of the vocal cords from abductor disorder. (during the phase of expiration (left) / inspiration (right)) Cervical computed tomography (CT). Computed tomography revealed a 6–mm retropharyngeal hematoma (red arrow). 経鼻胃管による咽頭への影響は1939年Wangensteen 1により初めて報告され，その後しばしば症例報告が散見される程度であった。1981年Sofferman 2は，経鼻胃管留置中に咽頭痛，片側あるいは両側の声帯の外転機能不全を来す症候群を経鼻胃管症候群と定義した。診断は，喉頭ファイバースコピー検査で声帯麻痺と診断し，かつ原因となりうる疾患を除外したうえで，臨床的に診断することが多い。発症のタイミングは経鼻胃管を留置して12時間後から抜去2週間後まで多様である 3。 病態は完全には解明されておらず，機序として，①咳嗽や嚥下の際に固定された経鼻胃管と咽頭が垂直方向へ摩擦が起きること，②仰臥位で輪状後部が頸椎側から経鼻胃管により圧迫される，③輪状咽頭筋の収縮が経鼻胃管を脆弱で薄い輪状軟骨後板へ持続的に引き上げる，といったことが推測されている 2。その結果，経鼻胃管による輪状後部への持続的圧迫から結果的に潰瘍形成や感染，虚血が生じ，後輪状披裂筋の機能不全が生じると考えられている 2, 4。糖尿病や低免疫状態，低栄養，加齢に伴う粘膜弾性の低下，パーキンソン症候群，脳血管障害に伴う生理的な嚥下運動の減少による除圧頻度の減少，輪状軟骨レベルでの骨棘突出がリスク因子と言われている 2, 5, 6。経鼻胃管の太さがリスク因子とする報告はない。桜井ら 7による10Frの経鼻胃管を留置していた4例の報告があり，決して細いチューブがリスクを軽減するわけではないと考えられる。またチューブの径が太い方が輪状後部への影響を与える可能性は高く，リスクとなりうると考えるが，今後検討すべき事項である。Friedmanらは，経鼻胃管が声帯部を正中で走行するのは約6%と少ないものの，動物モデルで側方を走行するより正中を走行する方が炎症を生じやすい可能性があると報告している 8。 本症例において，初療時のCT画像や第3病日のMRI画像では声帯自体や輪状軟骨後部を含め声門周囲の直接的な外傷性変化は指摘できなかった。咽頭後間隙の血腫は第1病日のCTで6mm，第3病日のMRIで5mmであった（Fig. 1, 3）。リスク因子は入院後に発症した麻痺性イレウスの影響による低栄養のみであった。経鼻胃管はCT画像で確認する限り，声門部では側方を通過していた。喉頭ファイバースコピー検査の際も側方を通過しているのを確認できた。入院後は頸髄損傷のため，仰臥位での安静時間がほとんどであった。しかし，頸髄損傷で経鼻胃管の留置が必要であった患者はこれまで多く経験しているが，当院で経鼻胃管症候群と診断したのは初めてであり，頸髄損傷などで輪状軟骨レベルでの損傷がある外傷症例での経鼻胃管症候群の報告は，我々が渉猟する限り見られなかった。以上から，本症例では低栄養状態や長期臥床の影響だけでなく，リスク因子として知られている輪状軟骨レベルの骨棘突出と同様の機序で，頸部外傷による咽頭後間隙の血腫・炎症性変化が経鼻胃管による輪状後部への刺激を増強し，炎症や虚血を起こしたのではないかと考えられた。頸髄損傷に偶発的に合併した可能性は否定できないが，椎体前面の外傷性変化が一因となり，経鼻胃管症候群を発症しうることが示唆された。椎体前面に血腫を形成する頸髄損傷の症例には重症度の差がある。軽症例では，通常経口摂取が可能で経鼻胃管が留置される可能性は高くない。一方，重症例では，腹式呼吸や喀痰喀出困難を原因とした呼吸不全に対する気管挿管のタイミングで経鼻胃管が留置されることが多い。その後十分な声帯の評価が行われずに気道確保や気管切開が行われていることが多く，経過中に経鼻胃管症候群を発症していても認知されていない可能性がある。本症例は腹式呼吸を呈するような重症例ではなかったものの，イレウスを発症したことで経鼻胃管が留置され，頸椎前面の外傷性炎症と相まって，経鼻胃管症候群の発症に至った。それに加え，咳嗽減弱や喀痰喀出困難をそれまで認めていなかったという経過から，本症に気づくことができたのではないかと考えた。 治療は経鼻胃管の抜去が必須とされている 9。その他，抗菌薬やPPI，副腎皮質ステロイドなどが投与された報告はあるが，確立した治療法はない。声帯外転障害が改善せず気管カニューレが抜去できないこともある 3。本症例では，治療上経鼻胃管を抜去することは困難であり，まずは経鼻胃管を減圧の治療の障害にならない範囲で細いものに入れ替えたのちに，経鼻胃管を留置している限り短期間での治癒は見込めないと判断し，気管切開術を行った。発症から29日後に声帯麻痺の治癒を確認できた。検索する限り今まで経鼻胃管を抜去せずに経鼻胃管症候群が治癒したという報告は見られなかった。治癒までの期間は長くなるかもしれないが，本症例のように治療上必要であれば経鼻胃管を抜去せずとも治癒する可能性があることが示唆された。 本症例は外傷症例の亜急性期に発生した吸気性喘鳴を契機に，各疾患を除外してから経鼻胃管症候群と診断できた。経鼻胃管症候群は比較的近年に定義された症候群であり，とくに2010年以降の症例報告が増加している 7, 9。これに関しては，経鼻胃管の留置数が著明に増加しているわけではないと考えられることから，発症する頻度が増加したわけではなく，この疾患の概念が認識され始めたことに影響しているものと推測された。対応が遅れると致命的となりうるだけでなく，本疾患を鑑別に入れておかないと経鼻胃管を抜去するなどの対応が遅れ，治癒までの期間が延長しうる。とくに救命・集中治療部門において経鼻胃管は留置されていることの多いデバイスであり，経鼻胃管を留置する際は本合併症に留意して管理を行う必要がある。 椎体前面の外傷性変化が一因になったと考えられた経鼻胃管症候群の1例を経験した。経鼻胃管はよく留置されるデバイスであり，両側声帯麻痺を発症した場合，緊急気道確保を行うとともに，経鼻胃管症候群を鑑別に挙げて治療を行う必要がある。 本論文の要旨は第122回近畿救急医学研究会（2021年，大阪）で発表した。 本稿のすべての著者に規定された利益相反はない。

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

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

Pain in the neck: Bench press injury.

A 49-year-old man with a history of hepatitis C infection presented to the emergency department with neck pain and hoarseness immediately after a blunt neck injury. He was bench pressing a 100 kg barbell when the safety bar broke. The bar slowly landed on his neck and remained there for a few seconds. On examination, his vital signs were normal except for hypertension, 167/106 mm Hg. His neck was tender to palpation, without swelling or ecchymosis. He had hoarseness, but the airway was patent without stridor. He showed no signs of respiratory distress. Computed tomography (CT) scan showed thyroid cartilage fracture and right arytenoid hematoma (Figure 1). Flexible fiberoptic laryngoscopy performed in the emergency department confirmed a right arytenoid hematoma with intact airway (Figure 2). Platelet count and prothrombin time-international normalized ratio were normal. Due to concerns of an impending airway emergency from the hematoma, he stayed in the observation unit for 12 hours. A second fiberoptic laryngoscopy on the next day showed no enlargement of the hematoma. He was discharged with close follow-up and recovered without any adverse events. Blunt laryngeal trauma is a rare but potentially life-threatening condition often caused by motor vehicle collisions, sport-related injuries, physical assaults, and strangulation. Clinically, it can cause neck pain, hoarseness, dyspnea, stridor, ecchymosis, crepitus, and airway obstruction.1 The first step in management is to assess and, if necessary, secure the airway. CT scan and flexible fiberoptic laryngoscopy are the key diagnostic tests for suspected laryngeal injury.2 A high index of suspicion and judicious use of diagnostic modalities are required as some patients with significant injuries may not have obvious signs of trauma, as in this case. Patients with high-grade injuries may require surgical intervention.3 Early intervention is the key to a good functional outcome.4

Knowledge, Exposure and Practice of Health Care Workers Regarding Emergency Airway Management in a Tertiary Care Centre of West Bengal: Questionnaire-Based Analytical Study

Background: Endotracheal intubation is an essential resuscitative procedure in the emergency setting, to maintain a patent airway. In our day-to-day practice at a tertiary care centre calls for intubation remain in quite a demand. As we all know in the emergency setting we first advocate maintaining the so-called A (airway), B(breathing) and C(circulation) and this is where lies the importance of intubation.
 Objective: The study was done to assess the knowledge, competency, and exposure regarding emergency airway management among healthcare workers in this region of West Bengal which caters to patients from the Mahananda Basin, in particular, Malda.
 Methodology: A questionnaire-based cross-sectional study was conducted. The study tool was a standard questionnaire containing 14 questions, which was developed to assess the knowledge, exposure, and practice of the study group in a Tertiary Care Centre of West Bengal.
 Results: the questionnaire based analytical study revealed gross lack of knowledge among caregivers regarding management of airway during emergency situations.
 Inference: Basic knowledge in terms of theory seems to prevail among almost all the participants but they lack the congruity between knowledge and exposure, hence an interactive curriculum should be designed to train the target groups in order to avoid the catastrophe seen during emergency situations.

Acute lethargy, stridor, and hypoxemia in a young adult.

A young adult with intellectual delay presented to the emergency department (ED) from a group home via ambulance with altered mental status and respiratory distress. The patient was known to be non-verbal but definitely alert and interactive at baseline. On arrival, the patient was lethargic with frequent coughing and notable stridor, unable to obey commands. Emergency medical services reported SpO2 was initially 85%, but the hypoxemia had improved with supplemental oxygen administered via non-rebreather mask. Partial airway obstruction was suspected due to the stridor, and it was feared that the paralysis of rapid sequence intubation might result in a “can't oxygenate, can't ventilate” scenario. Preparations were made for immediate emergency airway management with a dual set-up for awake fiberoptic tracheal intubation and a cricothyroidotomy. Nasal cannula was applied at flush rate with SpO2 sustained at 100% throughout the procedure. Ketamine was used to facilitate fiberoptic nasopharyngoscopy, which identified a green foreign body obstructing a view of the entire glottis. Standard geometry video laryngoscopy was then employed to guide foreign body retrieval with Magill forceps and a DuCanto (SSCOR, Inc) suction catheter (Video 1). It was evident during removal that the foreign body was aspirated broccoli. The patient recovered from sedation and had no further need for supplemental oxygen in the ED. The patient was treated for aspiration pneumonia, admitted for observation, and was discharged at their neurologic baseline the next day. Incomplete foreign body airway obstruction (FBAO) is a time-sensitive emergency that mandates urgent intervention before progression to complete obstruction, which will always rapidly deteriorate to cardiac arrest. Immediate removal is critical to patients surviving with good neurologic outcomes in the event of a cardiac arrest.1 Operators should be prepared to follow well-established algorithms for the management of incomplete and complete FBAOs.2 Magill forceps have been part of airway management for over a century3 and are known to be effective in removing FBAOs in prehospital cardiac arrests.4 The DuCanto (SSCOR, Inc) suction catheter is a wide-bore rigid suction catheter that has been shown to effectively remove viscous liquid in simulated airway contaminations5 but was successful in removing smaller solid foreign bodies for this case. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Early extracorporeal membrane oxygenation as bridge for central airway obstruction patients caused by neck and chest tumors to emergency surgery

Central airway obstruction caused by neck and chest tumors is a very dangerous oncological emergency with high mortality. Unfortunately, there is few literature to discuss an effective way for this life-threating condition. Providing effective airway managements, adequate ventilation and emergency surgical interventions are very important. However, traditional airway managements and respiratory support has only limited effect. In our center, using extracorporeal membrane oxygenation (ECMO) as a novel approach to manage patient with central airway obstruction caused by neck and chest tumors has been adopted. We aimed to show the feasibility: using early ECMO to manage difficult airway, provide oxygenation and support surgical procedure for patients with critical airway stenosis caused by neck and chest tumors. We designed a single-center, small sample size retrospective study based on real-world. We identified 3 patients with central airway obstruction caused by neck and chest tumors. ECMO was used to ensure adequate ventilation to emergency surgery. Control group cannot be established. Because traditional manner very likely led to death of such patients. Details of clinical characteristics, ECMO, surgery and survival outcomes were recorded. Acute dyspnea and cyanosis were the most frequent symptoms. All patients (3/3) showed descending arterial partial pressure of oxygen (PaO2). Computed tomography (CT) revealed severe central airway obstruction caused by neck and chest tumors in all cases (3/3). All patients (3/3) had definite difficult airway. All cases (3/3) received ECMO support and emergency surgical procedure. Venovenous ECMO was the common mode for all cases. 3 patients weaned off ECMO successfully without any ECMO-related complications. Mean duration of ECMO was 3 h (range: 1.5–4.5 h). Under ECMO support, difficult airway management and emergency surgical procedure were finished successfully for all cases (3/3). The mean ICU stay was 3.3 days (range: 1–7 days), and the mean general ward stay was 3.3 days (range: 2–4 days). Pathology demonstrated the tumor dignity for 3 patients including 2 malignant cases and 1 benign case. All patients (3/3) were discharged from hospital successfully. We showed that early ECMO initiation was a safe and feasible approach to manage difficult airway for patients with severe central airway obstruction caused by neck and chest tumors. Meanwhile, early ECMO initiation could ensure security for airway surgical procedure.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation

BackgroundPatients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (AirtraqⓇ; Prodol Meditec) and nonchanneled (McGrathⓇ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated. ObjectiveOur aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway. MethodsA prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18–60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted. ResultsMean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0–1 for group M and median IDS score of 1; IQR 0–2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A. ConclusionsThe performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study

BackgroundCricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. ObjectiveWe report the incidence and indications for rescue surgical airways using a multicenter observational registry. MethodsWe performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. ResultsOf 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). ConclusionRescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.

Pre-hospital emergency cricothyrotomy in dogs part 2: Airway sealing and ventilation using cricothyrotomy tubes.

Cricothyrotomy (CTT) has been recommended for use in the pre-hospital setting for military working dogs and Operational K9s during airway emergencies. Although the CTT can establish a patent airway for spontaneous ventilation, the ability to seal the airway and provide positive pressure ventilation (PPV) using tubes designed for humans has not been determined. Using various CTT tubes placed in cadaver dog airways, this study aimed to determine: (1) Whether the tube cuff could create a functional airway seal with safe intra-cuff pressures; (2) The magnitude of delivered tidal volume (TV) loss during a standard breath to assess the possibility of delivering an adequate tidal volume with a bag-valve device (BVM); (3) The best performing tubes for either test; (4) The reasons behind the findings using observations from upper airway endoscopy, dissection, and measurements. Cadaver dogs of similar weights to MWD and Operational K9 breeds had various CTT tubes placed including three from commercial kits, a standard endotracheal tube, and a tracheostomy tube. The minimum occlusive volume technique was used to inflate the tube cuff and a pressure ≤ 48 cm H2O with an adequate seal was considered successful. Individual TVs were calculated for each dog and added to the volume lost during delivery of a standard breath from an ICU ventilator. Endoscopy and airway dissection were performed to assess the relationship between tubes cuffs and the airway. The tubes from the CTT kits performed poorly with regards to producing an airway seal with the H&H tube failing to seal the airway all tests. Tracheal dimensions were significantly associated with successful airway sealing (P = 0.0004). Tidal volume loss could be compensated using a BVM in 34/35 tests with the H&H tube in cadaver 8 the only to fail. Tracheal airway sealing is influenced by airway anatomy when tube cuffs are inflated to a target pressure and larger tubes do not always provide a better seal. The CTT tubes tested have the potential to facilitate ventilation with a BVM under the conditions set in this study. The 8.0 mm endotracheal tube performed the best and the H&H the worst in both tests.

Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach

BackgroundAirway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED...

Are the HEAVEN criteria reliable as a predictive tool for emergency airway management? A systematic review

Background: Airway management is one of the most vital skills used by advanced airway providers. Anticipating a difficult airway is crucial for the risk-benefit analysis and may help providers to determine the optimal airway management approach. Existing difficult airway assessment tools may have limited application in emergency airway management. In addition, these do not incorporate physiological factors. More recently, Davis and Olvera proposed the HEAVEN criteria as a novel difficult airway predictive tool for emergency airway management. The objective of this study is to review HEAVEN as a novel airway prediction tool. Material and Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results of a comprehensive search in three major databases, as well as hand searching, were screened in title/abstract and full-text stages. We included the journal articles which review HEAVEN as a novel airway prediction tool with both retrospective and prospective study designs. The population included patients requiring rapid sequence intubation (RSI) or delayed sequence intubation (DSI). Two investigators independently extracted the data with an electronic table in Microsoft Word. Due to the heterogeneity in included study designs, settings, methods, study outcomes, and measurement of the studies, we did not carry out a meta-analysis. The risk of bias (RoB) was assessed using Joanna Briggs Institute checklist. Results: Out of 103 records, only four studies were included. The most cited criterion was the anatomical challenge, which was significantly associated with first-attempt success in three studies. Most studies on HEAVEN did not support physiological factors as predictors of difficult intubation. Two studies reported significant associations between individual HEAVEN criteria and first-attempt success without desaturation. Some included studies reported significant associations between anatomical HEAVEN criteria (extremes of size, anatomical challenge, vomit/blood/fluid, and neck mobility) and difficult airway view. Furthermore, a prospective study reported that hypoxemia and vomit/blood/fluid were significantly associated with intubation complications. Based on the results of the RoB analysis, there wasn’t considerable bias in a great number of included studies. Conclusion: The HEAVEN criteria may represent a development over the traditional approaches. HEAVEN assessment tool considers both physiological and anatomical factors. In addition, all HEAVEN elements can be performed in emergent situations. The HEAVEN criteria seem to be a useful tool to predict difficult airways. There was a variation among studies in the definition of the difficult airway. There is currently no consensus on the definition of a difficult airway, which may explain some of the heterogeneity of the results of this systematic review. Due to the heterogeneity in included studies, we did not carry out a meta-analysis. Therefore, we suggested that future studies should consider homogeneous patient populations, a uniform study design, a matching study setting, and a widely accepted definition of the difficult airway to provide the opportunity to perform meta-analyses. The controversial results of studies highlighted a requirement for more prospective studies with an appropriate study design and considering the possible confounding factors to reach more reliable evidence.

Airway management during ongoing chest compressions-direct vs. video laryngoscopy. A randomised manikin study.

Tracheal intubation is used for advanced airway management during cardiac arrest, particularly when basic airway techniques cannot ensure adequate ventilation. However, minimizing interruptions of chest compressions is of high priority. Video laryngoscopy has been shown to improve the first-pass success rate for tracheal intubation in emergency airway management. We aimed to compare first-pass success rate and time to successful intubation during uninterrupted chest compression using video laryngoscopy and direct laryngoscopy. A total of 28 anaesthetists and 28 anaesthesia nurses with varied clinical and anaesthesiological experience were recruited for the study. All participants performed a tracheal intubation on a manikin simulator during ongoing chest compressions by a mechanical resuscitation device. Stratified randomisation (physicians/nurses) was performed, with one group using direct laryngoscopy and the other using video laryngoscopy. First-pass success rate was 100% (95% CI: 87.9% - 100.0%) in the video laryngoscopy group and 67.8% (95% CI: 49.3% - 82.1%) in the direct laryngoscopy group [difference: 32.2% (95% CI: 17.8% - 50.8%), p<0.001]. The median time for intubation was 27.5 seconds (IQR: 21.8-31.0 seconds) in the video laryngoscopy group and 30.0 seconds (IQR: 26.5-36.5 seconds) in the direct laryngoscopy group (p = 0.019). This manikin study on tracheal intubation during ongoing chest compressions demonstrates that video laryngoscopy had a higher first-pass success rate and shorter time to successful intubation compared to direct laryngoscopy. Experience in airway management and professional group were not significant predictors. A clinical randomized controlled trial appears worthwhile.

Human papillomavirus vaccination in Africa: An airway perspective.

Recurrent respiratory papillomatosis (RRP) is a chronic condition caused by Human papillomavirus six (HPV-6) and HPV-11 that involves the respiratory tract. Disease severity ranges from mild (hoarseness), through to severe (stridor, respiratory distress and airway emergencies). Africa has the fastest growing and youngest population of all the continents. It also has the greatest burden of cervical cancer. There is an association with infection of the oncogenic HPV strains and the strains responsible for RRP. It is reasonable to conclude that although RRP may be underestimated in low-to-middle-income countries, it poses a considerable health risk to Africa. The primary aim of this project was to assess the suitability of HPV vaccination coverage on the African continent. A prospective study was designed to consist of an online survey. It was distributed to 135 African otolaryngologists. Questions focussed on HPV vaccination programmes; whether they were government directed; and their rollout. Information from countries that had multiple otolaryngologists respond to the survey were compared. Additionally, data review and corroboration were performed. There were 58 (43%) participants from 19 countries. Nine countries reported a national vaccination programme (NVP), five used Cervarix; four used quadrivalent Gardasil. Collateral data revealed 18 of 54 countries had NVP in Africa and 26 countries had completed HPV vaccine pilot or demonstration projects. HPV vaccination in Africa should be urgently re-evaluated to include the HPV-6 and HPV-11 strains that cause JORRP, which have not been recognised during national vaccination programme planning.