Emergency Intubation Research Articles

The integral role of the clinical pharmacist in drug-assisted intubation at a newly established children\u2019s major trauma center

This commentary outlines how the clinical pharmacist can support the safe administration of emergency medications in trauma anesthesia for seriously injured children. Promoting the professional development of the clinical pharmacist provided an opportunity to strengthen a key step in our trauma care pathway. We describe the implementation of this process in a new hospital, which was to become the designated children’s trauma center for an entire country. Although the literature documents the use of pharmacists in emergency intubation, ours was a unique set of circumstances, where empowering the pharmacist in frontline clinical care provided additional quality assurance for rapid sequence induction and intubation in trauma. Medical simulation was a core part of socializing the advanced clinical practice role of pharmacy within the trauma team. It was our experience that the pharmacist helps to promote confidence and decision making among other members of the trauma team.

Critical Care Outreach Team During COVID-19: Ventilatory Support in the Ward and Outcomes.

During the coronavirus disease 2019 (COVID-19) outbreak, a critical care outreach team was implemented in our hospital to guarantee multidisciplinary patient assessment at admission and prompt ICU support in medical wards. In this paper, we report the activity plan results and describe the baseline characteristics of the referred subjects. We retrospectively evaluated data from 125 subjects referred to the critical care outreach team from March 22 to April 22, 2020. We considered subjects with a ceiling of care decision, with those deemed eligible assigned to level 3 care (ward subgroup), and those deemed ineligible admitted to the ICU (ICU subgroup). Quality indicators of the outreach team plan delivery included number of cardiac arrest calls, number of intubations in level 2 areas, and ineffective palliative support. We enrolled 125 consecutive adult subjects with a confirmed diagnosis of COVID-19. We did not report any emergency endotracheal intubations in the clinical ward. In the care ceiling subgroup, we had 2 (3.3%) emergency calls for cardiac arrest, whereas signs of ineffective palliative support were reported in 5 subjects (12.5%). Noninvasive forms of respiratory assistance were delivered to 40.0% of subjects in the ward subgroup (median 3 d [interquartile range (IQR) 2-5]), to 45.9% of subjects in the care ceiling subgroup (median 5 d [IQR 3-7]), and to 64.7% of subjects in the ICU subgroup (median 2.5 d [IQR 1-3]). Thirty of the 31 ward subjects (96.7%), 26 of the 34 ICU subjects, (76.4%), and 19 of the 61 ceiling of care subjects (31.1%) were discharged. In the context of a hospital and ICU surge, a multidisciplinary daily plan supported by a dedicated critical care outreach team was associated with a low rate of cardiac arrest calls, no emergency intubations in the ward, and appropriate palliative care support for subjects with a ceiling of care decision.

Posterior reversible encephalopathy syndrome in a patient with Richter's syndrome on combination DA-R-EPOCH chemotherapy regimen: a case report

BackgroundPosterior reversible encephalopathy syndrome (PRES) is a clinical-radiologic entity characterized by headaches, altered mental status, seizures, visual loss, and a characteristic imaging pattern in brain magnetic resonance images. The exact etiology and pathogenesis of this condition are not yet fully elucidated.Case presentationA 72-year-old White man presented with 2 weeks of low-grade fever and chills, night sweats, fatigue, dysphagia, and new-onset rapidly increasing cervical lymphadenopathy. He had a history of chronic lymphocytic leukemia with transformation to diffuse large B-cell lymphoma for which he was started on dose-adjusted rituximab, etoposide, prednisone vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH). Shortly after treatment initiation, the patient developed severe airway obstruction due to cervical lymphadenopathy that required emergency intubation. A few days later, the cervical lymphadenopathy and the status of the airway improved, and sedation was consequently weaned off to plan for extubation. However, the patient did not recover consciousness and developed generalized refractory seizures. Brain magnetic resonance imaging revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes, consistent with PRES.ConclusionsPosterior reversible encephalopathy syndrome refers to a neurological disorder and imaging entity characterized by subcortical vasogenic edema in patients who develop acute neurological signs and symptoms of a usually reversible nature in different settings, including chemotherapy. Despite its name, PRES is not always fully reversible, and permanent sequelae can persist in some patients. Clinicians should be aware of the possible association between chemotherapy and PRES to ensure early recognition and timely treatment.

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. Tracheal intubation. The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.

The Success Rate of Endotracheal Intubation in the Emergency Department of Tertiary Care Hospital in Ethiopia, One-Year Retrospective Study.

Background Emergency medical care starts with airway assessment and intervention management. Endotracheal intubation is the definitive airway management in the emergency department (ED) for patients requiring a definitive airway. Successful first pass is recommended as the main objective of emergency intubation. There exists no published research regarding the success rates or complications that occur within Ethiopian hospitals emergency department intubation practice. Objective This study aimed to assess the success rate of emergency intubations in a tertiary hospital, Addis Ababa, Ethiopia. Methodology. This was a single institute retrospective documentation review on intubated patients from November 2017 to November 2018 in the emergency department of Addis Ababa Burn Emergency and Trauma Hospital. All intubations during the study period were included. Data were collected by trained data collectors from an intubation documentation sheet. Result Of 15,933 patients seen in the department, 256 (1.6%) patients were intubated. Of these, 194 (74.9%) were male, 123 (47.5%) sustained trauma, 65 (25.1%) were medical cases, and 13(5%) had poisoning. The primary indications for intubation were for airway protection (160 (61.8%)), followed by respiratory failure (72(27.8%)). One hundred and twenty-nine (49.8%) had sedative-only intubation, 110 (42.5%) had rapid sequence intubation, and 16 (6.2%) had intubation without medication. The first-pass success rate in this sample was 70.3% (180/256), second-pass 21.4% (55/256), and third-pass 7.4% (19/256), while the overall success rate was 99.2% (254/256). Hypoxia was the most common complication. Conclusion The intubation first-pass success rate was lower than existing studies, but the overall intubation success rate was satisfactory.

Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy

BackgroundTracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative.MethodsWe conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider’s level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy.ResultsFPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers’ expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified.ConclusionAirway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Incidence, Complications, and Factors Associated with Out-of-Hospital First Attempt Intubation Failure in Adult Patients: A Secondary Analysis of the CURASMUR Trial Data

Objectives: The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients. Material and methods: The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors. Results: A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06–4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11–1.87]. Conclusion: Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications.

Airway management in children with COVID-19.

The novel coronavirus disease (COVID-19) may result in acute respiratory distress syndrome and respiratory failure, necessitating mechanical respiratory support. Healthcare professionals are exposed to a particularly high risk of contracting the virus while providing resuscitation and respiratory support, which may in turn result in grave consequences and even death. Although COVID-19 has been shown to cause milder disease in children, paediatricians and intensivists who provide care for children must be prepared to provide optimal respiratory support without putting themselves or other medical, nursing, and paramedical staff at undue risk. We propose an airway management approach that is especially relevant in the current COVID-19 pandemic and provides instructions for: (1) Elective intubation for respiratory failure; and (2) Emergency intubation during cardiopulmonary resuscitation. To minimise risk, intubation methods must be kept as straightforward as possible and should include the provision of appropriate personal protection and equipment to healthcare workers. We identify two key considerations: that bag-mask ventilation should be avoided if possible and that bacterial and viral filters should be placed in the respiratory circuit. Our novel approach provides a framework for airway management that could benefit paediatric critical care practitioners who provide care for any children with a novel viral illness, with a focus on infection prevention during high-risk airway management procedures.

Superior Laryngeal Nerve Block for Intubation in Patients With COVID-19.

Coronaviruses are thought to primarily spread via respiratory droplets and close or direct contact. Transmission is also possible through prolonged exposure to high concentrations of virally infected aerosols in a relatively closed environment.1 Once generated, these aerosols reportedly remain suspended in the air for up to 3 hours.2 Certain clinical procedures such as intubation and extubation are particularly known to generate potentially contagious aerosols that could infect medical personnel.3 Canelli et al4 recently invented an “aerosol box,” a barrier that can be easily fabricated, to reduce the risk of viral transmission and infection via exposure to contaminated aerosols for clinicians performing intubation- and extubation-related procedures. This barrier consists of a transparent plastic cube that encases the patient's head, with 2 circular ports through which clinicians can insert their hands to manage the airway with minimal exposure. However, this box restricts hand mobility and requires prior training before use in actual clinical procedures.5Ponnappan et al6 analyzed their preliminary experience using the aerosol box during 30 endotracheal intubations performed by anesthesiologists at the Institute of Liver and Biliary Sciences, New Delhi. The mean experience of the anesthesiologists involved in that study was 5.3 years after completion of anesthesia training. Successful intubation was achieved in 38.1% of cases during the first attempt. A second attempt was required in 28.6% of cases, and removal of the aerosol box was required in 28.6% of cases because of poor vision and/or inadequate space to facilitate proper airway management. In difficult intubation cases in which it was necessary to intubate while spontaneous ventilation was maintained, success rates while using the aerosol box would have likely decreased significantly.Reducing coughing during intubation could contribute to a reduction in viral transmission and exposure among health care workers. Coughing can be reduced by several techniques such as the administration of nebulized lidocaine to anesthetize the airway or intravenous boluses of opioid agonists for cough suppression, among others. In our hospital, we use moderate sedation with midazolam and fentanyl for patients with suspected difficult intubation or airway management. Once the patient is adequately sedated, a bilateral superior laryngeal nerve (SLN) block (SLNB) can be performed to further reduce coughing during intubation, because the block effectively prevents contraction of the cricothyroid muscle. The block can be performed percutaneously without ultrasound guidance (Figure). Therefore, even when the need for emergent intubation unexpectedly becomes apparent, it can be performed relatively easily and quickly. The SLN provides sensation to the upper part of the larynx (and lower part of the pharynx).7–10 SLNB has been used to facilitate awake endotracheal intubations during endoscopic laryngeal surgeries.11,12 Alessandri et al13 reported that SLNB reduced cough and discomfort during awake fiber-optic intubations. However, this block can be associated with potential complications, including intravascular injection and nerve damage. Nevertheless, we believe that cough suppression via bilateral SLNB can be a useful approach for reducing aerosol generation during airway management (ie, intubation). It must be mentioned that appropriate personal protective equipment still remains necessary for adequate protection at all times, particularly during this pandemic.We do not have any experience intubating patients infected with SARS-CoV-2, the virus that causes the novel coronavirus disease 2019 (COVID-19). However, we are of the opinion that SLNB is likely to be effective in reducing coughing and aerosol generation during difficult airway management in patients with COVID-19.

Anesthesia for children with complete trisomy 18 (Edwards syndrome): A cohort review of 84 anesthesia encounters in nine patients.

Trisomy 18 or Edwards syndrome is the second most common aneuploidy with a prevalence between 1/3000 and 1/10000 live births. The syndrome encompasses malformations of the central nervous, cardiac, respiratory, gastrointestinal, and genitourinary systems. Trisomy 18 carries a poor prognosis with 90% of patients not surviving beyond 1year of age; however, the current trend toward more aggressive supportive care may prolong survival. The limited anesthesia literature highlights the abnormal airway anatomy but generally describes uneventful airway management and perioperative course. Our goal was to review all anesthesia encounters recorded for eleven trisomy 18 patients treated at Children's Wisconsin during the study period to explore the frequency of anesthesia encounters and to improve our understanding of the perioperative risks. We performed a retrospective chart review of all patients with trisomy 18 who were treated at our institution between 2012 and 2017. Records were screened for anesthesia encounters, perioperative critical events and complications, enrollment in palliative care, code status, and time of death. Eleven children were identified. Children were born between 2001 and 2016. Two children never required anesthesia care. Nine patients had a total of 84 anesthesia encounters for 121 surgical or diagnostic procedures or emergent intubations. Critical events and perioperative complications included difficult mask ventilation (n=7), difficult intubation (n=15), and mechanical or pharmacological cardiopulmonary resuscitation (n=6). Five patients presented with difficult peripheral intravenous access. One patient died in the immediate postoperative period. On five occasions, patients required emergent intubation outside of the operating room. Difficult airway management and respiratory compromise were critical concerns during the perioperative period in our patient population, and the inability to ventilate could lead to cardiorespiratory arrest. This case series provides a comprehensive, longitudinal view of complete trisomy 18 patients in the perioperative period and adds information for counseling families and care providers.

Role of Trachway versus Conventional Modes of Intubation in Difficult Airway Management in COVID-19 Setups.

Difficult airway management in critically ill patients remains a difficult task associated with high morbidity and mortality rates. In difficult airway populations, prompt effective intubation is more important to prevent hypoxia and neurological injury. During the ongoing COVID-19 pandemic, prolonged intubation time and repeated intubation can lead to an increase in the risk of infection. Therefore, digital devices can shorten intubation times and decrease the risk of infection among clinical staff. The advantages of the Trachway videolight intubating stylet suit these conditions. Trachway stylet intubation is an effective method for video laryngoscopy to enhance patient safety and improve the intubation success rate. However, a few studies have focused on the effect of stylet intubation by reducing repeated intubation and oxygen desaturation. In this study, we reviewed current data of Trachway intubation and shared our four major training scenarios in Taipei Tzu Chi Hospital via the Trachway videolight intubating stylet system for emergency intubation, comparing them with other modes of intubation.

Will Protective Innovations Like the "Airway Box" Become Routine Practice After the Pandemic?: An Opinion Survey.

BackgroundTracheal intubation carries an elevated risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the generation of aerosols containing high concentrations of the virus. An airway box was designed to mitigate the exposure of healthcare professionals performing intubations.AimWe evaluated usability and sustainability in the routine practice of the "airway box" as a protective device during high-risk airway procedures. Materials and methodsAfter institutional review board approval, clinicians were educated on using the device through simulation, intranet learning modules, and emailed resources. The airway box was made available in the emergency department, critical care units, perioperative area, and operating rooms. QR codes affixed to the box, emailed, and displayed in common areas provided easy access to complete a REDcap survey (Vanderbilt University Nashville, USA) eliciting providers’ experience. Data was collected and analyzed between April 1 and July 31, 2020, on REDcap, and the results were analyzed.Results687 emergent intubations took place. 232 were performed by anesthesiologists, 315 by emergency department providers, and 140 by critical care specialists. 39 surveys were completed, 29 from intubations in the operating room, three from the critical care units, five from interventional radiology suites, and two perioperatively. Providers found the device to be readily available, with a score of 4.51/5, and the majority of providers, 60%, found the device easy to use, rating it either a 4 or 5 out of 5. Providers acquired a mean Mallampati score of 1.75 and 1.40 mean laryngoscopic grade view.ConclusionIntubation boxes may effectively mitigate high-risk viral exposure during airway procedures. Survey responses show that devices were easy to use and did not significantly affect visualization of the airway. Similar to mask use, enclosure devices in clinical practice could become a vital part of medical protective equipment even after the SARS-CoV-2 pandemic if they are effectively implemented.

English

BACKGROUND First-pass success is the successful intubation on the first attempt. It is the desired goal of emergency intubation and failure to achieve it may increase the risk of adverse effects. With failure of first pass intubation, life-threatening complications occur, commonly in critically ill patients. The aim of this study is to determine the association between the success of first-pass intubation and frequency of adverse events during endotracheal intubation. METHODS A cross sectional analytical study was done in a tertiary care hospital between October 2016 and October 2017. 100 failed first-pass intubation cases and 100 successful first-pass intubation cases were evaluated for factors associated with failed first-pass intubation and frequency of adverse events following intubation. RESULTS The groups were matched with respect to gender, induction agent use, fentanyl use and type of laryngoscope used. Mean age in failed first-pass intubation group was 5.61 years higher than subjects in successful first-pass intubation group (P = 0.016). Proportion of subjects with difficult airway was 19 % in failed first-pass intubation group and 3 % in successful first-pass intubation (P &lt; 0.001). Failed first-pass intubation cases had higher frequency of adverse events like oesophageal intubation (9 % vs. 0 %), aspiration (7 % vs. 1 %), cuff leakage (2 % vs. 0 %) and hypotension (7 % vs. 1 %) compared to successful first-pass intubation cases. CONCLUSIONS The frequency of adverse events was high in failed first-pass intubation. Older age and presence of difficult airway were factors significantly associated with failed first-pass intubation. KEYWORDS First Pass Intubation, First-Pass Success, Adverse Events, Emergency Department, Failed First Attempt, Endotracheal Intubation

Emergency airway management in a Singapore centre: A registry study

Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore. We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described. There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians. In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.

Comparison between dexmedetomidine and acepromazine in combination with methadone for premedication in brachycephalic dogs undergoing surgery for brachycephalic obstructive airway syndrome

ObjectiveTo compare dexmedetomidine with acepromazine for premedication combined with methadone in dogs undergoing brachycephalic obstructive airway syndrome (BOAS) surgery. Study designRandomized, blinded clinical study. AnimalsA group of 40 dogs weighing mean (± standard deviation) 10.5 ± 6 kg, aged 2.6 ± 1.9 years. MethodsDogs received either acepromazine 20 μg kg–1 (group A) or dexmedetomidine 2 μg kg–1 (group D) intramuscularly with methadone 0.3 mg kg–1. Anaesthesia was induced with propofol and maintained with sevoflurane. Sedation (0–18), induction (0–6) and recovery (0–5) qualities were scored. Propofol dose, hypotension incidence, mechanical ventilation requirement, extubation time, additional sedation, oxygen supplementation, regurgitation and emergency intubation following premedication or during recovery were recorded. Data were analysed using t tests, Mann-Whitney U or Chi-square tests. ResultsGroup A dogs were less sedated [median (range): 1.5 (0–12)] than group D [5 (1–18)] (p = 0.021) and required more propofol [3.5 (1–7) versus 2.4 (1–8) mg kg–1; p = 0.018]. Induction scores [group A: 5 (4–5); group D 5 (3–5)] (p = 0.989), recovery scores [group A 5 (4–5); group D 5(3–5)](p = 0.738) and anaesthesia duration [group A:93 (50–170); group D 96 (54–263) minutes] (p = 0.758) were similar between groups. Time to extubation was longer in group A 12.5 (3-35) versus group D 5.5 (0–15) minutes; (p = 0.005). During recovery, two dogs required emergency intubation (p > 0.99) and five dogs required additional sedation (p > 0.99). Oxygen supplementation was required in 16 and 12 dogs in group A and D, respectively (p = 0.167); no dogs in group A and one dog in group D regurgitated (p = 0.311). Conclusions and clinical relevanceDexmedetomidine 2 μg kg–1 produces more sedation but similar recovery quality to acepromazine 20 μg kg–1 combined with methadone in dogs undergoing BOAS surgery.

Pediatric ANCA- Associated Vasculitis Presenting with Acute Postoperative Subglottic Stenosis: A Case Report

Introduction: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) often present with nonspecific constitutional symptoms. However, there has been increasing recognition of a subgroup of young, female AAV patients who are at higher risk for isolated subglottic airway disease. Case Presentation: We report a rare case of a 17-year-old female with undiagnosed ANCA-associated vasculitis who presents with acute, life threatening subglottic stenosis requiring emergent intubation after routine surgery. Conclusion: Much of the research on ANCA-associated vasculitis have been based on adult cases, however many pediatric patients may not follow the same diagnostic and clinical presentations. Clinicians should be vigilant in recognizing a subgroup of vasculitis patients who are often young, female, and have a higher prevalence of subglottic stenosis. Symptoms should be promptly worked up and initiation of immunosuppressive therapy is necessary to prevent life threatening complications and end-organ damage. Keywords: ANCA-associated vasculitis, Subglottic stenosis, Granulomatosis with polyangiitis.

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients

BackgroundEfficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia.MethodsA prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups.ResultsOf 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation).Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation.ConclusionApnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

Efficacy of prophylactic methylprednisolone on reducing the risk of post-extubation stridor in patients after an emergency intubation: study protocol for a randomized controlled trial

BackgroundPost-extubation stridor (PES) is one of the most common complications of invasive respiratory support, with severe cases leading to possible extubation failure (reintubation within 48 h) and increased mortality. Previous studies confirmed that prophylactic corticosteroids play an important role in reducing the risk of PES and extubation failure. However, few studies have looked at the efficacy of corticosteroids on preventing PES in patients after an emergency intubation.AimTo evaluate whether a single dose of methylprednisolone given over a set timeframe before extubation is effective in preventing PES in patients after an emergency intubation.MethodsA multicenter, randomized, placebo-controlled trial will be performed in an emergency department (ED) setting. The trial will include 132 patients who fail a cuff-leak test (CLT) prior to the intervention. Patients will be randomly assigned to either intravenous methylprednisolone (40 mg) or placebo 4 h prior to extubation. Other eligible patients who pass the CLT will be included in a non-intervention (observation) group. The primary endpoint is the incidence of PES within 48 h after extubation. Secondary endpoints include oxygen therapy, respiratory support requirements, reintubation secondary to PES, adverse effects within 48 h after extubation, hospital length of stay, and hospital mortality.DiscussionPatients who are intubated on an emergency basis have a higher risk of intubation-related complications. Previous studies have examined treatment regimens involving more than 10 different variations on corticosteroid treatments for PES prevention, while for ED therapy, only a simple and effective treatment would be appropriate. Corticosteroid administration is usually accompanied by adverse effects; thus, this study will be important for further risk stratification among intubated ED patients.Trial registrationChictr.org.cn ChiCTR2000030349. Registered on 29 February 2020.

Clinical Course of Amyotrophic Lateral Sclerosis according to Initial Symptoms: An Analysis of 500 Cases.

PurposeOne obstacle in early diagnosis of amyotrophic lateral sclerosis (ALS) is its vague initial presentation, which is generally classified into limb- and bulbar-dominant types and may be mistaken for other musculoskeletal conditions. We analyzed clinical data from patients in relation to their initial presentation and prognosis from symptom onset to diagnosis.Materials and MethodsWe retrospectively analyzed the medical records of patients with ALS who were admitted for pulmonary rehabilitation between January 2007 and December 2019. We collected data on time of onset, initial presenting symptoms, unnecessary operations due to misdiagnosis, and the time between symptom onset and final diagnosis of ALS.ResultsAmong 500 patients, unnecessary operations were performed in 43 patients. The median durations between symptom onset and ALS diagnosis for patients with and without operations were 11 and 9 months, respectively (p=0.008). 67.0%, 28.8%, and 4.2% of the patients presented with limb-, bulbar-, and respiratory-dominant symptoms, respectively, as initial presentations. The median ages at symptom onset were significantly different for limb-, bulbar-, and respiratory-dominant onset (57.5, 60.6, and 66.7 years, respectively; p<0.001). Compared to the other two types, patients with the respiratory-dominant onset were all male and showed higher rate of emergent endotracheal intubation before ALS diagnosis.ConclusionInappropriate operations significantly delayed the diagnosis of ALS. Respiratory difficulty can account for a significant proportion among initial presentations in ALS. Compared to limb- and bulbar-dominant types, respiratory-dominant onset appears to show male predominance, older age at symptom onset, and poor respiratory prognosis.

Teaching Review on Approach for Emergency Intubation

Abstract Background Physicians commonly secure the airway with the aid of rapid sequence intubation (RSI)-also called drug assisted intubation- in an acutely unstable patient. As these patients are at high risk of aspiration the RSI is especially useful as it combines medications and techniques to minimize this risk. In addition, the RSI also helps to reduce the potential adverse effects of airway manipulation. Therefore, we aim to look into RSI for both medical students and new physicians face in the recognition, diagnosis and management of maintaining a secure patent airway. Targeted population Emergency Physicians needs of teaching protocol of RSI. Aim of the study Appropriate approach of RSI by training protocol to Emergency Physicians. Based on practice gaps for preventive death and adverse long-term complications of airway problems. Methods Collection of all possible available data about the RSI with its complications in the Emergency department (ED). By many research questions to achieve these aims so a midline literature search was performed with the keywords "critical care", "emergency medicine", "principals of airway management", "Endotracheal Intubation", "RSI" Literature search from Emergency Room (ER) view included an overview of with recent definition, causes and recent therapeutic strategies. Results All studies introduced that the initial diagnosis of airway problems and its management is a lifesaving conditions that face patients of in ED and intensive care unit (ICU). Conclusion RSI guidelines will help resolve much of the guesswork that many primary care providers have to consider when evaluating cases who have sustained some form of maintaining secure patent airway troubles. Clinicians can say that the preoxygenation is very important to prevent Hypoxemia and its complication, and the importance of the rapid sequence intubation.