Definitive Airway Management Research Articles

Pre-hospital emergency anaesthesia in the United Kingdom: an observational cohort study

BackgroundUp to one in eight trauma patients arrive at a hospital with a partially or completely obstructed airway. The UK National Institute for health and Care Excellence (NICE) practice guidelines recommend that trauma patients requiring anaesthesia for definitive airway management receive this care within 45 min of an emergency call, preferably at the incident scene. How frequently this target is achieved remains unclear. We assessed the recorded time to pre-hospital emergency anaesthesia after trauma across UK helicopter emergency medical service (HEMS) units. MethodsWe retrospectively recorded time to pre-hospital emergency anaesthesia across all 20 eligible UK HEMS units (comprising 52 enhanced care teams) from April 1, 2017 to March 31, 2018. Times recorded for emergency notification, dispatch, arrival, and neuromuscular blocking agent administration were analysed. ResultsHEMS undertook 1755 pre-hospital emergency anaesthetics for trauma across the UK during the study period. There were 1176/1755 (67%) episodes undertaken by helicopter response teams during daylight hours. The median time to pre-hospital emergency anaesthesia was 55 min (inter-quartile range: 45–70); anaesthesia within 45 min of the initial emergency call was achieved in 25% cases. Delayed dispatch time (>9 min) was associated with fewer patients receiving pre-hospital anaesthesia within 45 min (odds ratio: 7.7 [95% confidence intervals: 5.8–10.1]; P<0.0001). ConclusionsThe time to achieve pre-hospital emergency anaesthesia by UK HEMS frequently exceeds the recommended 45 min target. Reducing the time to dispatch of emergency medical teams may impact on the delivery of pre-hospital emergency anaesthesia.

Pediatric Difficult Airway Response Team Utilization in the Emergency Department: A Case Series.

A multidisciplinary pediatric difficult airway team was created at our institution to respond to hospital-wide airway emergencies. We report the characteristics, indications, and outcomes of these activations that occur in the pediatric emergency department (PED). Retrospective, single-center cohort study comprised all difficult airway team activations occurring in the PED from the program's inception in 2008 to 2018. Ages of ≤18 years were included. For each case, detailed information was abstracted, including patient factors, PED context and milieu, airway interventions, and airway outcomes. There were 15 difficult airway response team activations in the PED during the study period, or 1.4 activations per year. The most common indications for activation were contaminated airways (n = 7; 47%) and history of difficult intubation (n = 4; 27%). Definitive airway management was successful in all cases, except for a single case where intervention was unnecessary. The most commonly performed definitive airway intervention was direct laryngoscopy (n = 6; 40%). There were no instances of emergency front-of-neck access. Difficult airways in the PED were uncommon. Most cases were resolved with familiar equipment including direct laryngoscopy, video laryngoscopy, and supraglottic airways.

Defining atypical croup: A case report and review of the literature

BackgroundCroup is a common respiratory illness in children. It presents with a barky cough, stridor and hoarseness occurring secondary to inflammation of the subglottis and larynx. The clinical course of croup is well-described, however atypical presentations pose a diagnostic and management challenge. ObjectivesThis case report and systematic review aims to synthesize the published literature on the definition, diagnosis and treatment of atypical croup. Study selectionPeer-reviewed journal publications in Ovid MEDLINE® and EMBASE from inception to January 1, 2019 in English, focusing on pediatric patients (<18 years of age) with diagnoses of atypical croup. Data extractionPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ResultsTwelve studies involving 670 patients ranging from 6 months to 11 years of age presenting with atypical croup were selected. A variety of definitions of atypical croup were identified based on recurrence, duration of symptoms, severity, and etiology. Data on the incidence of atypical croup, the overall rates of intubation and tracheostomy, and patient characteristics leading to definitive airway management were not clearly characterized. LimitationsAll studies were case series, case reports or retrospective chart reviews. ConclusionsAtypical croup is a poorly defined clinical entity that is used to describe recurrent, refractory, or croup-like illness that follows an uncharacteristic natural history. Our case presentation and accompanying literature review highlights the variable, but limited, information available on the diagnosis of atypical croup. Given the commonality of its use in clinical practice, we propose some guidelines around the use of the term ‘atypical croup’ as well as a management algorithm.

Acute Deterioration of an Intubated COPD Patient - A Case Report

Dealing with respiratory failure associated with exacerbation of chronic obstructive pulmonary disease (COPD) is not an uncommon scenario in intensive care units (ICUs). We present the case of an elderly man presenting to the emergency department (ED) with an infective exacerbation of COPD due to community acquired pneumonia. This case highlights an unexpected event following definitive airway management and its clinical course.

Paediatric airway management and concerns: a survey of advanced paramedics in Ireland.

Paediatric airway management is of fundamental importance in the critically unwell child. Pre-hospital paediatric airway management especially endotracheal intubation is however controversial. To explore Irish Advanced Paramedics (APs) training, experience and clinical practice in paediatric airway management as well as to examine clinician attitudes toward this topic. An anonymous online survey of all graduates of the University College Dublin AP training program (N = 453). With duplicates and failed email deliveries excluded a valid sample of 382 individuals was obtained from whom a response rate of 185/382 (48.4%) was achieved. Three quarters of responding APs worked in urban or mixed practice with the remaining minority operating primarily in rural areas. One quarter of responding APs reported formal training in paediatric intubation. Almost 70% of APs had encountered a child requiring significant airway management in the preceding year. However, this was a rare exposure in terms of overall workload. Basic airway adjuncts were used frequently in such circumstances, with endotracheal intubation having been attempted by only a small minority of APs. Lack of practice was identified by many responding APs as a key issue causing concern in terms of paediatric intubation. Paediatric airway management has key relevance for pre-hospital care in Ireland. The overall frequency of exposure to children who may benefit from definitive airway management is however likely to represent a significant barrier to the acquisition and maintenance of competency. The ongoing practice of pre-hospital paediatric intubation by APs may not justify its risks.

Variation in the accuracy of ultrasound for the detection of intubation by endotracheal tube size

IntroductionRapid and accurate confirmation of endotracheal tube (ETT) placement is a fundamental step in definitive airway management. Multiple techniques with different limitations have been reported. Recent studies have evaluated the accuracy, time to performance, and physician confidence for ultrasound in both cadaveric models and live patients. However, no study to date has measured the effect of ETT size. Our study is the first to measure the accuracy of ultrasound for ETT confirmation based on ETT size. MethodsThis study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumferences. Cadavers were intubated in a random sequence with respect to both the location of intubation (i.e., tracheal vs esophageal) and sizes of ETT. Three ETT sizes were utilized: 6.0-, 7.0-, and 8.0-mm. Blinded sonographers assessed the location of the ETT using the static technique. Accuracy of sonographer identification, time to identification, and operator confidence were assessed. Results453 assessments were performed. Overall, ultrasound was 99.1% (95% CI 97.8% to 99.7%) accurate in identification of correct location of intubation. The mean time to placement was 6.45 s (95% CI 5.62 to 7.28). The mean operator confidence level was 4.72/5.0 (95% CI 4.65 to 4.78). There was no significant difference between ETT sizes with respect to any of the outcomes. ConclusionThe diagnostic accuracy of ultrasound for ETT confirmation did not vary with the use of different ETT sizes. Further studies are needed to determine if the accuracy would change with more novice providers or in specific patient populations.

LO34: Does utilization of an intubation safety checklist reduce dangerous omissions during simulated resuscitation scenarios?

Introduction: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.

LO43: Perceptions of airway checklists and the utility of simulation in their implementation emergency medicine practitioner perspectives

Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.

Pre-hospital i-gel blind intubation for trauma: a simulation study.

ObjectiveThis study aimed to evaluate the efficacy of i-gel blind intubation (IGI) as a rescue device for definitive airway management in ground intubation for pre-hospital trauma patients.MethodsA prospective randomized crossover study was conducted with 18 paramedics to examine intubation performance of two blind intubation techniques through a supraglottic airway devices (IGI and laryngeal mask airway Fastrach), compared with use of a Macintosh laryngoscope (MCL). Each intubation was conducted at two levels of patient positions (ground- and stretcher-level). Primary outcomes were the intubation time and the success rate for intubation.ResultsThe intubation time (sec) of each intubation technique was not significantly different between the two positions. In both patient positions, the intubation time of IGI was shortest among the three intubation techniques (17.9±5.2 at the ground-level and 16.9±3.8 at the stretcher-level). In the analysis of cumulative success rate and intubation time, IGI was the fastest to reach 100% success among the three intubation techniques regardless of patient position (all P<0.017). The success of intubation was only affected by the intubation technique, and IGI achieved more success than MCL (odds ratio, 3.6; 95% confidence interval, 1.1 to 11.6; P=0.03).ConclusionThe patient position did not affect intubation performance. Additionally, the intubation time with blind intubation through supraglottic airway devices, especially with IGI, was significantly shorter than that with MCL.

Emergency Airway Management in Neck Trauma

Airway management in patients who have sustained direct trauma to the airway is among the most challenging problems for emergency clinicians. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway obstruction. Immediate, definitive airway management is needed when the patient cannot protect his airway or is unable to sufficiently oxygenate or ventilate. Emergent or urgent airway management is specified when a patient develops respiratory distress or when symptoms are progressing rapidly. In addition, airway management often is indicated when the patient appears clinically stable, but the clinician anticipates clinical decline (e.g., smoke inhalation, edema, subcutaneous air, hematoma) or feels that an unprotected airway presents a risk to the patient who requires transport to another facility or to radiology for extensive diagnostic studies. The higher rate of complicated airways in this population mandates that the clinician has to be prepared to use advanced airway techniques, including a surgical airway.

Acute Management of Tension Pneumocephalus in a Pediatric Patient: A Case Report

BackgroundTension pneumocephalus is a rare but life-threatening condition in which air gains entry into the cranium and exerts mass effect on the brain, resulting in increased intracranial pressure. It occurs most frequently secondary to head trauma, particularly to the orbits or sinuses. Case ReportA 13-year-old male sustained facial trauma from a motor vehicle collision and was found to have tension pneumocephalus on computer tomography. The patient underwent immediate rapid sequence intubation without preceding positive pressure ventilation in the emergency department. At the time of his craniotomy, the tension pneumocephalus was found to have resolved and he went on to have a complete recovery. Why Should an Emergency Physician Be Aware of This?Any patient with facial or head trauma and pneumocephalus is at risk for the potential development of tension pneumocephalus. When present, we advocate that aggressive definitive airway management by rapid sequence intubation without preceding positive pressure ventilation and early surgical management should be prioritized.

Definitive airway management after prehospital supraglottic rescue airway in pediatric trauma

IntroductionSupraglottic airway (SGA) use and outcomes in pediatric trauma are poorly understood. We compared outcomes between patients receiving prehospital SGA versus bag mask ventilation (BVM). MethodsWe reviewed pediatric multisystem trauma patients (2005–2016), comparing SGA and BVM. Primary outcome was adequacy of oxygenation and ventilation. Additional measures included tracheostomy, mortality and abbreviated injury scores (AIS). ResultsNinety patients were included (SGA, n=17 and BVM, n=73). SGA patients displayed increased median head AIS (5 [4–5] vs 2 [0–4], p=0.001) and facial AIS (1 [0–2] vs 0 [0–0], p=0.03). SGA indications were multiple failed intubation attempts (n=12) and multiple failed attempts with poor visualization (n=5). Median intubation attempts were 2 [1–3] whereas BVM patients had none. Compared to BVM, SGA patients demonstrated inadequate oxygenation/ventilation (75% vs 41%), increased tracheostomy rates (31% vs 8.1%), and increased 24-h (38% vs 10.8%) and overall mortality (75% vs 14%) (all p<0.05). ConclusionsEscalating intubation attempts and severe facial AIS were associated with tracheostomy. Inadequacy of oxygenation/ventilation was more frequent in SGA compared to BVM patients. SGA patients demonstrate poor clinical outcomes; however, SGAs may be necessary in increased craniofacial injury patterns. These factors may be incorporated into a management algorithm to improve definitive airway management after SGA.

Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients

BackgroundPrehospital airway management increasingly involves supraglottic airway insertion and a paucity of data evaluates outcomes in trauma populations. We aim to describe definitive airway management in traumatically injured patients who necessitated prehospital supraglottic airway insertion. MethodsWe performed a single institution retrospective review of multisystem injured patients (≥15years) that received prehospital supraglottic airway insertion during 2009 to 2016. Baseline demographics, number and type of: supraglottic airway insertion attempts, definitive airway and complications were recorded. Primary outcome was need for tracheostomy. Univariate and multivariable statistics were performed. Results56 patients met inclusion criteria and were reviewed, 78% were male. Median age [IQR] was 36 [24–56] years. Injuries comprised blunt (94%), penetrating (4%) and burns (2%). Median ISS was 26 [22–41]. Median number of prehospital endotracheal intubation (PETI) attempts was 2 [1-3]. Definitive airway management included: (n=20, 36%, tracheostomy), (n=10, 18%, direct laryngoscopy), (n=6, 11%, bougie), (n=9, 15%, Glidescope), (n=11, 20%, bronchoscopic assistance). 24-hour mortality was 41%. Increasing number of PETI was associated with increasing facial injury. On regression, increasing cervical and facial injury patterns as well as number of PETI were associated with definitive airway control via surgical tracheostomy. ConclusionsAfter supraglottic airway insertion, operative or non-operative approaches can be utilized to obtain a definitive airway. Patients with increased craniofacial injuries have an increased risk for airway complications and need for tracheostomy. We used these factors to generate an evidence based algorithm that requires prospective validation. Level of evidenceLevel IV – Retrospective study. Study typeRetrospective single institution study.

Management Options (Algorithms) for Mediastinal Masses Presenting with Impending Airway Obstruction

Mediastinal masses can have varied presentations or may even remain silent till very late. There is paucity of literature on acute presentation and management of patients with unrecognised mediastinal masses in the emergency or critical care set up. In patients with impending airway obstruction, standard medical management fails to improve the condition and definitive airway management with positive pressure ventilation may worsen the condition further. A cardiothoracic surgeon opinion should be sought early and femoral vessels may be cannulated prophylactically. Facilities for institution of life support or ECMO2 (extra-corporeal membrane oxygenation) is desirable in intensive care units caring for patients with mediastinal masses. This article depicts the algorithm for management of acute respiratory distress due to hitherto undiagnosed airway-compressing mediastinal masses.

An Airway Rapid Response System: Implementation and Utilization in a Large Academic Trauma Center

Rapid response teams mobilize resources to patients experiencing acute deterioration. Failed airway management results in death or anoxic brain injury. A codified, systems-based approach to bring personnel and equipment to the bedside for multidisciplinary airway assessment and rescue was reflected in the initial implementation of an airway rapid response (ARR) team. A retrospective review of records of 117 ARR events in a 40-month period (August 2011-November 2014) was undertaken at the Hospital of the University of Pennsylvania, a 789-bed, academic, urban, tertiary care, Level 1 trauma center. Of the 117 ARR events, 60 (51.3%) were called in the ICU, and 43 (36.8%) in the general ward. A definitive airway was secured in all patients for whom airway management was attempted. A new surgical airway was performed in five of the patients. Seven patients went to the operating room for airway management. Nine patients died or had care withdrawn shortly after the ARR. Difficult airway emergencies represent a small but critical element of airway rescue scenarios. Before the implementation of the ARR system, the process to bring the right team, equipment, expertise, and consensus on the right actions to critical airway emergencies was ad hoc. ARR activation, which brings multidisciplinary airway consultation, expert skills, and advanced airway equipment to the bedside, contributed to definitive airway management for surgical and nonsurgical airways. Performance of a bedside emergency surgical airway was uncommon. The ARR system represents a significant enhancement of the "anesthesia stat" system that typifies the airway emergency system at many institutions.

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

BackgroundThe effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS.MethodsData were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran–Mantel–Haenszel methods and mixed-effects models.ResultsEight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4–5.4).ConclusionsOur results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.Trial registrationClinicaltrials.gov Identifier: NCT01502111. Registered 22 Desember 2011.

Post-resuscitation care.

Following return of spontaneous circulation (ROSC) after cardiac arrest, the challenge is to institute measures that ensure a higher likelihood of neurologically intact survival. Regardless of the cause of collapse, multiple organ systems may be affected secondary to post-cardiac arrest syndrome. Interventions required for post-ROSC care are bundled into a care regimen: prompt identification and treatment of the cause of cardiac arrest; and treatment of electrolyte abnormalities. It is also essential to establish definitive airway management to maintain normocapnic ventilation, prevent hyperoxia, and optimise haemodynamic management via judicious intravenous fluids and vasoactive drugs. Targeted temperature management after ROSC confers neuroprotection and leads to improved neurological outcomes. Glycaemic control of blood glucose levels at 6-10 mmol/L, adequate seizure management and measures to optimise neurological functions should be integrated into the care bundle. The interventions outlined can potentially lead to more patients being discharged from hospital alive with good neurological function.

Management and reconstruction of blast wounds of the head and neck.

The purpose of this review is to highlight recent literature related to the initial management and reconstruction of blast injuries to the head and neck. An increasing percentage of combat-related injuries are caused by blast trauma. Management of blast trauma over the last 10 years has improved understanding of the unique nature of these injuries and the importance of thoughtful management and reconstruction. Blast trauma is associated with an increased need for definitive airway management. As a result, initial triage principles of airway management and hemorrhage control are extremely important in the acute setting. Blast trauma results in high-velocity injuries that can lead to extensive soft tissue damage, which has important implications for reconstruction. Staging reconstruction is an important consideration for more extensive injuries. Experience on the battlefield with blast injuries over the last decade has led to efficient triage with focus on hemorrhage and airway control. The lessons learned in Iraq and Afghanistan with the unique physiology of blast trauma have improved the casualty care of service members and can be used both in future military conflicts and in civilian trauma care.

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

BackgroundThe insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical...

Initial Evaluation and Triage of the Injured Patient: Mechanisms of Injury and Triggers for Operating Room Versus Emergency Department Stabilization

Trauma anesthesiologists are uniquely juxtaposed with the multidisciplinary trauma team, serving both an administrative role in preparing the operating room (OR) and allocating resources for resuscitation, and a direct patient care role, providing definitive airway management and advanced resuscitation. Trauma anesthesiologists must have an intimate understanding regarding mechanisms of injury, appropriate diagnostic modalities, and current practices regarding OR versus emergency department or radiology suite (IR) resuscitation. In this review, current practices regarding assessment and triage, mechanisms of injury, and the concepts of surgical, orthopedic, and radiology “damage control” approaches to the severely injured trauma patient are discussed.