Emergency Airway Management Research Articles

Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study.

AimTracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics—particularly the location, patient, and provider factors—in the pediatric ED.MethodsWe conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre‐ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors.ResultsOf 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre‐ED setting and 177 were intubated in the ED. The overall first‐attempt success rate was 72%, with the rate varying by location, patient, and provider factors—for example, 68% at the pre‐ED setting, 67% for children <2 years, 56% for children with airway‐related anatomical anomalies, and 61% with intubation by a resident physician. Intubation‐related adverse events were observed in 17%, most of which were hypoxemia (14%).ConclusionsBased on data from a multicenter prospective study, the overall first‐attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.

Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department

BackgroundChallenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric...

Quantitative evaluation of aerosol generation during manual facemask ventilation.

SummaryManual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol‐generating procedure. This designation is based on one epidemiological study suggesting an association between facemask ventilation and transmission during the SARS‐CoV‐1 outbreak in 2003. There is no direct evidence to indicate whether facemask ventilation is a high‐risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation and facemask ventilation with an intentionally generated leak in anaesthetised patients. Recordings were made in ultraclean operating theatres and compared against the aerosol generated by tidal breathing and cough manoeuvres. Respiratory aerosol from tidal breathing in 11 patients was reliably detected above the very low background particle concentrations with median [IQR (range)] particle counts of 191 (77–486 [4–1313]) and 2 (1–5 [0–13]) particles.l‐1, respectively, p = 0.002. The median (IQR [range]) aerosol concentration detected during facemask ventilation without a leak (3 (0–9 [0–43]) particles.l‐1) and with an intentional leak (11 (7–26 [1–62]) particles.l‐1) was 64‐fold (p = 0.001) and 17‐fold (p = 0.002) lower than that of tidal breathing, respectively. Median (IQR [range]) peak particle concentration during facemask ventilation both without a leak (60 (0–60 [0–120]) particles.l‐1) and with a leak (120 (60–180 [60–480]) particles.l‐1) were 20‐fold (p = 0.002) and 10‐fold (0.001) lower than a cough (1260 (800–3242 [100–3682]) particles.l‐1), respectively. This study demonstrates that facemask ventilation, even when performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, we argue facemask ventilation should not be considered an aerosol‐generating procedure.

1505 EASiE: ENT and Airway Simulation in Emergencies

Abstract Aim A literature review of undergraduate ENT teaching found that most final year medical students and junior doctors did not feel adequately prepared for clinical practice in ENT. Other surveys found junior doctors lack confidence in recognising or initiating management in patients with blocked tracheostomies. To improve this, we ran a simulation session designed to replicate airway emergencies that junior doctors should be able to manage. The aim was to improve confidence in and knowledge of basic management of airway emergencies, including tracheostomies. Method Groups of 4-6 final year medical students participated in 3 scenarios: 2 tracheostomy-related and 1 partially compromised airway. The students had attended a session introducing tracheostomies and the algorithms produced by the National Tracheostomy Safety Project for tracheostomy emergencies. A semi-structured debrief followed each scenario, highlighting key learning points. The students completed a pre- and post-session questionnaire, rating confidence in several domains related to the scenarios. Results Of 24 participants, the percentage of students who felt confident or very confident in the following domains were compared pre- and post-simulation respectively: recognising a potential airway problem (0% vs 71%); identifying an altered airway (0% vs 75%); managing a potentially compromised surgical airway (4% vs 71%); initially managing a compromised airway (8% vs 67%); and identifying when to escalate with a potential airway problem (25% vs 96%). Conclusions Simulation is a valuable tool that can be used to improve both knowledge and confidence in managing potential airway problems in final year medical students. This supports findings from other studies.

Share the Airway: An Interdisciplinary Course for Management of the Unexpected Difficult Airway

IntroductionWithin the scope of practice of oral and maxillofacial surgery, the unexpected difficult airway may occur in the trauma bay, operating theater, postoperative, or office-based setting. Oral and maxillofacial surgeons must be trained to diagnose and intervene in anatomically or anesthetically compromised airways. An interdisciplinary training course hosted by an anesthesiology airway expert and oral and maxillofacial surgeon is a novel resident training opportunity. Materials and methodsIn August 2019 and October 2020, the department of anesthesiology and the division of oral and maxillofacial surgery at Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, NY, co-hosted interdisciplinary educational sessions focused on management of the unexpected difficult airway, taught to residents and faculty. A SurveyMonkey (San Mateo, CA) questionnaire was taken 2 weeks before and after the course, with 10 questions assessing fund of knowledge in airway anatomy and physiology, etiology of difficult airway scenarios, difficult airway algorithm, and performance of emergency surgical airways. An interactive lecture on likely scenarios, airway algorithms, relevant surgical anatomy, routine and emergency airway management, airway devices, and emergency surgical airway techniques was conducted. A hands-on cricothyroidotomy tutorial using Crico-Trainer “Pig” (VBM, Sulz, DE) anatomic models with fresh porcine tracheas to simulate human airway anatomy were used. A post-course test consisted of a timed, filmed performance followed by a debriefing session. ResultsIncreased fund of knowledge and comfort with airway anatomy, difficult airway diagnosis and management, and emergency surgical airway techniques was evident between pre-and post-course surveys and was clearly demonstrated across multiple years. The sample size (n = 10, 2019; n = 7, 2020) was insufficient for statistical analysis. ConclusionInterdisciplinary didactic and clinical training in emergency airway management are of paramount importance to the oral and maxillofacial surgeon. Between years, a drop-off in knowledge base and technical skills occurred, even among senior staff, and all attendees agreed that periodic repetition is worthwhile. This course is now offered as part of the core curriculum on an annual basis and may be expanded to additional specialties for whom airway management is important.

SUBMANDIBULAR SPACE AIRWAY OBSTRUCTION: A RARE PRESENTATION OF MYXEDEMA COMA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myxedema coma is an uncommon manifestation of severe hypothyroidism. Classically, as symptoms of hypothyroidism progresses patients exhibit signs of myxedema including generalized edema, ptosis and hypoventilation. Rarely, myxedema coma can present with isolated mucin collections around the salivary glands and facial skin. This causes progressive facial swelling leading to airway obstruction, requiring emergent advanced airway management CASE PRESENTATION: A 37-year-old male presented to an outside hospital with worsening altered mental status, progressive submandibular swelling, stridor, and acute hypoxic respiratory failure. His past medical history included hypothyroidism and cerebral palsy. His vitals prior to transfer were unremarkable other than tachypnea and hypoxia with an O2 saturation of 85%. Labs at the outside hospital revealed a leukocytosis of 15K and euvolemic hyponatremia with a sodium of 127. Due to the patients worsening respiratory status he was emergently intubated. The patient was transferred to our ICU for a higher level of care. On arrival, the patient was hypothermic with a temperature of 94.7F, and in sinus bradycardia with a rate of 54. He was also hypotensive requiring norepinephrine. IV antibiotics were initiated. On examination, he had firm, fixed submandibular swelling with no palpable fluctuating mass. His exam was otherwise unremarkable. The patient underwent a CT scan of the head and neck with contrast which showed nonspecific soft tissue swelling without evidence of abscess or infection. Further Infectious disease workup was unremarkable. A TSH was ordered and found to be significantly elevated at 60 with an undetectable T4 level, consistent with myxedema coma. Endocrinology was consulted and the patient was promptly started on IV levothyroxine. Over the next several days his mental status improved with stabilization of his vital signs. His submandibular swelling improved and the patient was subsequently extubated. He was eventually discharged home. DISCUSSION: Facial swelling is a known manifestation of myxedema coma. These manifestations classically present as dry facial skin, periorbital facial, and tongue swelling. Rarely, myxedema coma can present with isolated submandibular facial swelling leading to progressive airway compromise requiring emergent intubation. Vitals signs expected with myxedema coma may not initially be present. Mortality in these patients is approximately 30%. Myxedema coma must be ruled out in patients with progressive airway compromise as it can be effectively treated, however to miss the diagnosis is lethal. CONCLUSIONS: Although infectious and hypersensitive conditions are common causes, myxedema coma should be on a clinician's differential diagnosis for progressive facial swelling. Evaluation for myxedema coma is standard of care in patients with progressive airway obstruction. REFERENCE #1: Wall, C., 2021. Myxedema Coma: Diagnosis and Treatment. [online] Aafp.org. Available at: <https://www.aafp.org/afp/2000/1201/p2485.html> [Accessed 6 April 2021]. REFERENCE #2: Susan S. Braithwaite, Critical Care Medicine (Third Edition), Mosby,2008, Pages 1281-1306, ISBN 9780323048415, https://doi.org/10.1016/B978-032304841-5.50063-7. (https://www.sciencedirect.com/science/article/pii/B9780323048415500637) REFERENCE #3: Leonard Wartofsky, Myxedema Coma?, Editor(s): Ilpo Huhtaniemi, Luciano Martini, Encyclopedia of Endocrine Diseases (Second Edition), Academic Press,2018, Pages 627-629, ISBN 9780128122006, https://doi.org/10.1016/B978-0-12-801238-3.04171-4. (https://www.sciencedirect.com/science/article/pii/B9780128012383041714) DISCLOSURES: No relevant relationships by Zachary Fyffe, source=Web Response No relevant relationships by Matthew Mitchell, source=Web Response

Effectiveness of Teaching Program on Knowledge of Clinical Nurses Regarding Risk of Unplanned Extubation of Patients with Mechanical Ventilation at a Selected Hospital, Bangalore

Background: Mechanical ventilation (MV) is one of the therapeutic pillars of intensive care medicine. Technique and practice in emergency airway management varies between ICUs and in different countries and as a result, complication rates may also differ. Unplanned extubation is a frequent event after endotracheal intubation for respiratory support in critically ill patients and is associated with increased morbidity and mortality. The incidence of unplanned extubation among intubated patients is reported to vary from 0.3% to 1.4%. Unplanned extubation account for approximately 10% of reintubations. An Unplanned Extubation is also associated with prolonged duration of mechanical ventilation, ICU stay and hospital stay. Objective: to assess the knowledge of clinical nurses regarding risk of unplanned extubation of patients with mechanical ventilation at Kempegowda institute of medical science and research Hospital, Bangalore, Karnataka. Materials and Methods: Quantitative research approach and a pre-experimental one group pre-test post-test research design were used to accomplish the stated objectives. The investigator selected a sample of 50 nurses who were working in KIMS hospital. The data were collected by using a self administered structured knowledge questionnaire. Planned teaching was given with appropriate A-V aid followed by pretest. Result: Inferential and descriptive statistical analysis was performed by using SPSS-IBM 20. Results were calculated by using p value &lt; 0.05. The results revealed that, in pretest 80% of the nurses had inadequate knowledge where as in posttest 82% of the nurses had gained moderately adequate knowledge and the improvement was statistically significant at P&lt;0.05. Conclusion: The study result shows that after intervention knowledge regarding risk of unplanned extubation among nurses were improved significantly. Keywords: Effectiveness planned teaching, risk of unplanned extubation, knowledge of staff nurses and mechanical ventilation protocol.

Prospective observational study of the endotracheal intubation complications in Emergency Department

Endotracheal intubation is the gold standard intervention for emergency airway management. Complications related to endotracheal intubation are numerous and frequent. Complications were identified as being related to endotracheal intubation in our study: hypoxia, hypotension, dysrhythmia, cardiac arrest, hypertension, tachycardia, bradycardia, regurgitation and aspiration of stomach contents, endobronchial intubation, and incorrect positioning of the endotracheal tube in either the esophagus or hypopharynx. The study included 186 patients that were over 18 and intubated. The complication rate associated with endotracheal intubation was found to be over 50%. Patients included in our prospective, observational study were all initially evaluated in our ED. A survey was filled out at a time as soon as possible after intubation to record the personnel in charge of intubation, details of the procedure, and hemodynamic changes and complications. Our study found that the following factors were associated with increased rates of complication in intubated patients: history of acute renal failure, history of cancer, GCS &lt; 8, midazolam use during intubation, history of trauma, crash intubation, history of shock, history of cardiac arrest, resident with &lt;1 year of experience carrying out the intubation, residents with 2+ years of experience and specialists carrying out the intubation, history of respiratory failure, and patient age &lt;65. To better understand which patients were likely to be affected by complications associated with intubation, as well as to understand which precautions to take, this study aims to investigate the aggravating factors and complication rates of endotracheal intubation.

Retrospective Analysis of COVID-19 Conversion Rate Among Anesthesiologists in Acute Care Centers.

Brief description of the primary research objectiveAmong healthcare workers, anesthesiologists are regarded as frequently exposed frontline providers in the fight against COVID-19 due to their proximity to patient airways and involvement in aerosolized procedures. As such, the risk of contracting the COVID-19 virus as an occupational hazard is presumed to be higher. To date, in most published studies, all healthcare workers were grouped together, independent of specialty or profession. At the time that this survey was distributed, we did not find any peer-reviewed articles that differentiated COVID-19 infection rates among frontline, such as anesthesiologists vs. non-frontline healthcare workers. This retrospective survey’s primary research objective was to report the rate of COVID-19 infection among anesthesiologists compared to the general population of healthcare workers.MethodologyA survey was sent among anesthesiology attendings and residents in Northern New Jersey and Brooklyn, New York hospitals on duty during the peak pandemic from March 2020 to May 2020. Questions in the survey focused on infection rates and adherence to standards of infection precaution and personal protective equipment (PPE) utilization.Main FindingsThis retrospective study highlights the rate of infection among anesthesiologists as a particularly vulnerable subgroup of frontline residents and physicians, as they are called to duty when emergent airway management is required. In our study, the reported rate of contracting COVID-19 among anesthesiologists was 16.7%. This statistic is higher than the infection rates published by studies by New York State and the CDC.ConclusionThe survey sent to anesthesiologists is useful to understand the impact of COVID-19 on this subgroup of frontline providers and the importance of adhering to standards of infection protocol and the role of PPE.

Debriefing immediately after intubation in a children's emergency department is feasible and contributes to measurable improvements in patient safety.

In 2013, our intubations highlighted a safety gap - only 49% achieved first-pass success without hypoxia or hypotension. NAP4 recommended debriefing after intubation, but limited published methods existed. Primary aim is to implement a feasible process for immediate debriefing and feedback for emergency airway management. Secondary aims are to contribute to reduced frequency of adverse intubation-related events and implement qualitative improvements in patient safety through team reflection and feedback. A component of a prospective quality improvement (QI) study over 4 years in the ED of the Royal Children's Hospital, Melbourne, Australia. Debrief and feedback after intubation was one of seven study interventions. Targeted staff training and involvement of departmental leaders occurred. A post-intervention cohort was audited in 2016. Analysis included the Team Emergency Assessment Measure. Immediate post-event debriefing occurred in 39 (85%) of 46 intubations. Debriefing was short (median duration 5min, interquartile range [IQR] 5-10) and soon after (median time 20 min, IQR 5-60). Commonest location was the resuscitation room (92%), led by the team leader (97%). Commonest barrier preventing immediate debriefing was excessive workload. Two QI process measures were assessed during debriefing (adequate resuscitation, airway plan) and case summaries distributed for 100% of intubations. Performance outcomes included contribution to 78% first-pass success without hypoxia or hypotension. Team reflection prompted changes to environment (signage, stickers), training (skill drills), teamwork and process (communication, clinical event debriefing). Structured and targeted debriefing after intubating children in the ED is feasible and contributes to measurable and qualitative improvements in patient safety.

Factors Associated With Pediatric Emergency Airway Management by the Difficult Airway Response Team.

BackgroundThe goal of this study was to determine if difficult airway risk factors were similar in children cared for by the difficult airway response team (DART) and those cared for by the rapid response team (RRT).MethodsIn this retrospective database analysis of prospectively collected data, we analyzed patient demographics, comorbidities, history of difficult intubation, and intubation event details, including time and place of the emergency and devices used to successfully secure the airway.ResultsWithin the 110-patient cohort, median age (IQR) was higher among DART patients than among RRT patients [8.5 years (0.9-14.6) versus 0.3 years (0.04-3.6); P < 0.001]. The odds of DART management were higher for children ages 1-2 years (aOR, 43.3; 95% CI: 2.73-684.3) and >5 years (aOR, 13.1; 95% CI: 1.85-93.4) than for those less than one-year-old. DART patients were more likely to have craniofacial abnormalities (aOR, 51.6; 95% CI: 2.50-1065.1), airway swelling (aOR, 240.1; 95% CI: 13.6-4237.2), or trauma (all DART managed). Among patients intubated by the DART, children with a history of difficult airway were more likely to have musculoskeletal (P = 0.04) and craniofacial abnormalities (P < 0.001), whereas children without a known history of difficult airway were more likely to have airway swelling (P = 0.04).ConclusionSpecific clinical risk factors predict the need for emergency airway management by the DART in the pediatric hospital setting. The coordinated use of a DART to respond to difficult airway emergencies may limit attempts at endotracheal tube placement and mitigate morbidity.

Mechanical ventilation strategies

Any medical emergency resulting in a compromised airway will require emergency airway management, but subsequent continued airway support and artificial mechanical ventilation may also be needed. This article explores some of the common mechanical ventilation strategies and modes used during the COVID-19 pandemic and will discuss why coronary care nurses need to be familiar with these.

Advancing emergency airway management by reducing intubation time at a high-volume academic emergency department

BackgroundAirway management is a life-saving procedure in the emergency department (ED). Hypoxia during rapid sequence intubation (RSI) is associated with high morbidity and mortality.AimTo decrease the median time of intubation...

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies.

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Awake intubations in the emergency department: A report from the National Emergency Airway Registry.

To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance. We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs). Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]). Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.

Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor?

Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine. A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation. The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review. The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.

The evaluation of using new trachea and skin manikins for practicing emergency anterior neck access

Emergency anterior neck access may be performed if intubation and ventilation fail. Practicing this life-saving procedure with manikins before facing a real-life emergency anterior neck access is required to do this procedure successfully when we encounter a difficult airway situation. The current manikins are expensive and thus are sometimes difficult to acquire in low-cost settings such as Thailand. We devise a cost-effective training manikin using less expensive materials but retaining the simple design of the trachea and skin areas which are flexible polyurethane (PU) foam and silicone, but which still had the same utility as the current manikins. Five items were evaluated, and then scores were rated by experienced physicians from 1 to 5 points for each item, 1 being the least and 5 the highest. The mean score concerning the appropriate size of the manikins was 4.55 ± 0.56. The mean score of the ease of use for practicing was 4.58 ± 0.59. The mean score of the similarity of the skin of the manikins to human skin was 3.85 ± 0.66. The mean score of the similarity of the trachea of the manikins to the human trachea was 3.80 ± 0.69. The mean score of the sensation of inserting the tube in the manikin compared to a real trachea was 3.90 ± 0.67. The mean overall benefit score of practicing on the manikins was 4.38 ± 0.45. Our trial indicates that this low-cost and simply designed manikin can be useful for practicing emergency airway management procedures to save patients who are struggling with lack of oxygen or intubation failure or failure of ventilation or other airway equipment such as endotracheal intubation and supraglottic airway devices (SGA).

Emergency Airway Management of a Patient with Rosai-Dorfman Disease

Rosai-Dorfman disease is a rare histiocytic disorder that involves the over-production of non-Langerhans sinus histiocytes. It presents with cervical lymphadenopathy and huge neck swelling that could prove to be a challenging airway and a nightmare for anaesthesiologists. We discuss the airway management of a patient with Rosai-Dorfman disease requiring an emergency tracheostomy as a life-saving measure.

The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients.

The recommended rocuronium dose for rapid sequence intubation is 1.0mg/kg; however, the optimal dose for emergency airway management is not clear. We assessed the relationship between rocuronium dose and first-attempt success among emergency department (ED) patients undergoing rapid sequence intubation. This is a secondary analysis of the National Emergency Airway Registry (NEAR), an observational 25-center registry of ED intubations. Ninety percent recording compliance was required from each site for data inclusion. We included all patients > 14years of age who received rocuronium for rapid sequence intubation from 1 Jan 2016 to 31 Dec 2018. We compared first-attempt success between encounters using alternative rocuronium doses (< 1.0, 1.0-1.1, 1.2-1.3 and ≥1.4mg/kg). We performed logistic regressions to control for predictors of difficult airways, indication, pre-intubation hemodynamics, operator, body habitus and device. We also performed subgroup analyses stratified by device (direct vs. video laryngoscopy). We calculated univariate descriptive statistics and odds ratios (OR) from multivariable logistic regressions with cluster-adjusted 95% confidence intervals (CI). 19,071 encounters were recorded during the 3-year period. Of these, 8,034 utilized rocuronium for rapid sequence intubation. Overall, first attempt success was 88.4% for < 1.0mg/kg, 88.1% for 1.0-1.1mg/kg, 89.7% for 1.2-1.3mg/kg, and 92.2% for ≥1.4mg/kg. Logistic regression demonstrated that when direct laryngoscopy was used and when compared to the standard dosing range of 1.0-1.1mg/kg, the adjusted odds of a first attempt success was significantly higher in ≥1.4mg/kg group at 1.9 (95% CI 1.3-2.7) relative to the other dosing ranges, OR 0.9 (95% CI 0.7-1.2) for < 1.0mg/kg and OR 1.2 (95% CI 0.9-1.7) for the 1.2-1.3mg/kg group. First-attempt success was similar across all rocuronium doses among patients utilizing video laryngoscopy. Patients who were hypotensive (SBP < 100mmHg) prior to intubation had higher first-attempt success 94.9% versus 88.6% when higher doses of rocuronium were used. The rates of all peri-intubation adverse events and desaturation were similar between dosing groups, laryngoscope type utilized and varying pre-intubation hemodynamics. Rocuronium dosed ≥1.4mg/kg was associated with higher first attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension with no increase in adverse events. We recommend further prospective evaluation of the dosing of rocuronium prior to offering definitive clinical guidance.

Conceptualizing intubation sharing: A descriptive qualitative study of videolaryngoscopy for pediatric emergency airway management.

This study characterizes clinical and educational practices around the use of videolaryngoscopy in pediatric emergency airway management through qualitative exploration. This is a descriptive qualitative study using semi-structured interviews of emergency medicine physicians. Physicians were selected by theoretical sampling from urban, tertiary care pediatric hospitals across the United States until theoretical data saturation was achieved. The study applied a constructivist grounded theory approach to data collection and analysis. Manual line-by-line coding of interview transcripts was used initially, then grouped into categories with constant comparative analysis to generate the final coding scheme organized by themes and subthemes. Finally, memo-writing and iterative analysis meetings explored relationships between themes and identified an interpretive model. Theoretical saturation was achieved after 10 of the initial 12 interviews. Emerging from the data were six themes that describe the concept of intubation sharing: (1) Videolaryngoscopy encompasses multiple modalities that all provide a shared view and ability to record; (2) Airway experts and systems help realize the full potential of videolaryngoscopy; (3) Videolaryngoscopy can be a clinical, educational, quality assurance and research tool; (4) Some skills required for videolaryngoscopyareunique, while others overlap with direct laryngoscopy; (5) Videolaryngoscopy allows a coaching laryngoscopist to provide real-time guidance to the primary laryngoscopist from a shared view; (6) Videolaryngoscopy provides an opportunity for post-intubation coaching and feedback and shared learning from a single experience for the provider community. Through this multicenter qualitative interview study, we derived the concept of intubation sharing through videolaryngoscopy for real-time and remote coaching, for both the primary laryngoscopist and the community of emergency medicine providers who intubate.