Intubation In Group Research Articles

Advanced airway management is necessary in prehospital trauma patients

Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required. A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor-paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise. Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor-paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients. A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group.

A pilot study of less invasive surfactant administration in very preterm infants in a Chinese tertiary center.

BackgroundLess invasive surfactant administration (LISA) to spontaneously breathing preterm infants has been reported to reduce the duration of mechanical ventilation and the incidence of bronchopulmonary dysplasia (BPD) in previous study. The objective of this study was to explore the feasibility and potential benefits of LISA in early preterm infants on nasal continuous positive airway pressure (nCPAP) compared to conventional endotracheal instillation.MethodsAll infants with respiratory distress born at 28–32 weeks’ gestational age from January 2012 to December 2012 (n=90), who were eligible for exogenous pulmonary surfactant (PS) therapy were randomized to receive PS by intubation with an endotracheal tube (Intubation group, n=43), or by intubation using a catheter while on nCPAP (LISA group, n=47). Respiratory indices were recorded every 30 seconds during PS administration, and every 1 hour thereafter for the first day. The rate of mechanical ventilation (MV) in the first 72 hours, mean duration of both MV and nCPAP, mean duration of oxygen requirement and neonatal outcomes were recorded.ResultsPS was successfully administered in 43 (100%) out of 43 babies using the conventional approach and in 46 (97%) out of 47 babies using LISA. The duration of both MV and nCPAP was significantly shorter in LISA group, when compared with intubation group. However, there were no significant differences in both the rate of MV in the first 72 hours and mean duration of oxygen requirement. There were also no differences in the mortality or in the incidence of bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity and necrotizing enterocolitis, or in the duration of respiratory support.ConclusionsLISA in spontaneously breathing infants on nCPAP is an alternative therapy for PS delivery, avoiding intubation with an endotracheal tube. The method is feasible and potentially effective, and deserves further clinical trials.Trial registrationCurrent Controlled Trials ChiCTR-ICR-15006001. Registered 20 February 2015.

WITHDRAWN: A randomized trial to compare the Truview picture capture device, C-MAC laryngoscope, and Macintosh laryngoscope in pediatric airway management

To evaluate and compare the Truview picture capture device (PCD) and C-MAC laryngoscope to the standard Macintosh laryngoscope in pediatric patients. One hundred and fifty patients with American Society of Anesthesiology status Grade I-II (ASA I-II) who were 1-6 years old (10-20kg) were scheduled for elective surgery. They were randomized into three equal groups for laryngoscopy and intubation by either the Truview PCD (Group T), C-MAC (Group C), or Macintosh laryngoscope (Group M) under general anesthesia. The percentage of glottic opening (POGO) score, application of external laryngeal maneuver, time to intubation, number of attempts at intubation, failed intubations, episodes of desaturation, and trauma were recorded and statistically analyzed. A value of p<0.05 was considered significant. The POGO scores were significantly better with the Truview PCD (94.7±12.91) than with the C-MAC and Macintosh laryngoscopes (82±24.97 and 85.1±17.07, respectively; p<0.01). There were no failures, episodes of desaturation, or trauma in any of the patients. It took 19.24 seconds to intubate with the Truview PCD, compared to 12.32 seconds with the C-MAC laryngoscope and 10.7 seconds with the Macintosh laryngoscope (p<0.01). An external laryngeal maneuver was required in 42% of patients in group C, compared to 38% in Group M and 16% in group T (p<0.01). The Truview PCD offers the best laryngeal view, although it takes a longer time for intubation. The C-MAC laryngoscope provides similar laryngeal views as the Macintosh blade, and is an excellent teaching aid.

The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity.

The anticholinergic toxidrome is well described and relatively common. Despite controversy, studies have shown that physostigmine is relatively safe and effective in reversing this toxidrome. We would expect toxicologists would be liberal in its use. We retrospectively analyzed data in the Toxicology Investigators Consortium (ToxIC) registry, representing data from medical toxicologists in multiple institutions nationwide, searching for patients who exhibited an anticholinergic toxidrome, determining what treatment(s) they received, and classifying the treatments as physostigmine, benzodiazepines, physostigmine and benzodiazepines, antipsychotics, or no definitive treatment. The causal agents of the toxidrome were as reported by the treating toxicologist. Eight hundred fifteen consecutive patients with anticholinergic toxidromes were analyzed. Benzodiazepines alone were given in 28.7 %, 12.4 % were given physostigmine alone, 8.8 % received both physostigmine and benzodiazepines, 2.7 % were given antipsychotics, and 47.4 % were given no definitive treatment. In patients who received only physostigmine, there was a significant difference in the rate of intubation (1.9 vs. 8.4 %, OR 0.21, 95 % CI 0.05-0.87) versus other treatment groups. Physostigmine was given at varying rates based on causative agent with use in agents with mixed or unknown effects (15.1 %) being significantly lower than those with primarily anticholinergic effects (26.6 %) (p < 0.001). Patients with anticholinergic toxicity were more likely to receive benzodiazepines than physostigmine. Those patients who received only physostigmine had a significantly lower rate of intubation. Physostigmine was more likely to be used with agents exerting primarily anticholinergic toxicity than in those agents with multiple actions.

Akut hiperkapnik solunum yetmezliğinde noninvaziv mekanik ventilasyonun geç başarısızlığı için risk faktörleri

Non-invasive mechanical ventilation provides early improvement in most of the patients with acute hypercapnic respiratory failure. The aim of our study was to determine the risk factors for late failure of non-invasive mechanical ventilation in patients with acute hypercapnic respiratory failure. Ninety three patients were prospectively evaluated. Non-invasive mechanical ventilation was accepted to be successful if the patient was discharged from the hospital without the need for intubation (group 1) and to be late failure if a deterioration occurred after an initial improvement of blood gases tension and general conditions (group 2). Non-invasive mechanical ventilation was successful in 62 (66.7%) patients. In 25 (26.9%) patients a late failure was observed. There was no difference between groups 1 and 2 in terms of pretreatment pH, PaCO2 and PaO2/FiO2. However, serum C-reactive protein level, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and frequency of bronchiectasis and pneumonia were significantly higher and serum albumin level, Glasgow Coma Score, cough strength and compliance to non-invasive mechanical ventilation were significantly lower in group 2. The pretreatment high APACHE II Score and C-reactive protein level, low Glasgow Coma Score, albumin level, cough strength, bad compliance to non-invasive mechanical ventilation, the presence of bronchiectasis and pneumonia and absence of significance improvement in PaO2/FiO2 after treatment were determined as risk factors for non-invasive mechanical ventilation late failure.

Sensitivity of the Combination of Mallampati Scores with Anthropometric Measurements and the Presence of Malignancy to Predict Difficult Intubation.

The aim of this study was to determine the combinations of the Mallampati test and anthropometric measurements with the highest selectivity value. In addition, we aim to identify a possible correlation between head circumference measurement, the presence of malignancy and difficult intubation. Patients who were scheduled to undergo elective surgery under general anaesthesia, who fell into Group 1-2 according to ASA criteria and were between the ages of 18-70 years were included in the study. Patients with Cormack-Lehane scores of 3-4 were considered to be difficult intubations. Thyromental distance, sternomental distance, mandibular distance, neck length, neck circumference and head circumference were measured during the anthropometric measurements. According to the ROC analysis, there was a significant difference in the thyromental distance, sternomental distance, neck length, neck circumference and head circumference between the easy and difficult intubation groups (p<0.05). The incidence of difficult intubation was 8.3% in patients with non-head-neck malignancies, whereas the incidence was 7.1% in patients without any malignancies. The difference between these groups was not statistically significant (χ(2)=0.101; p=0.751). To predict the incidence of difficult intubation, the test with the highest selectivity and highest positive predictive values was the combination of Mallampati-thyromental distance. We believe that the head circumference and neck length measurement, in addition to the current anthropometric measurements, may be crucial to predict the incidence of difficult intubations. In addition, we believe that the anticipation of difficult intubations in patients with non-head-neck malignancies is not different from the normal population.

"Permissive hypoventilation" in a swine model of hemorrhagic shock.

Many penetrating trauma patients in severe hemorrhagic shock receive positive pressure ventilation (PPV) upon transport to definitive care, either by intubation (INT) or bag-valve mask (BVM). Using a swine hemorrhagic shock model that simulates penetrating trauma, we proposed that severely injured patients may have better outcomes with "permissive hypoventilation," where manual breaths are not given and oxygen is administrated passively via face mask (FM). We hypothesized that PPV has harmful physiologic effects in severe low-flow states and that permissive hypoventilation would result in better outcomes. The carotid arteries of Yorkshire pigs were cannulated with a 14-gauge catheter. One group of animals (n = 6) was intubated and manually ventilated, a second received PPV via BVM (n = 7), and a third group received 100% oxygen via FM (n = 6). After placement of a Swan-Ganz catheter, the carotid catheters were opened, and the animals were exsanguinated. The primary end point was time until death. Secondary end points included central venous pressure, cardiac output, lactate levels, serum creatinine, CO2 levels, and pH measured in 10-minute intervals. Average survival time in the FM group (50.0 minutes) was not different from the INT (51.1 minutes) and BVM groups (48.5 minutes) (p = 0.84). Central venous pressure was higher in the FM group as compared with the INT 10 minutes into the shock phase (8.3 mm Hg vs. 5.2 mm Hg, p = 0.04). Drop in cardiac output (p < 0.001) and increase in lactate (p < 0.05) was worse in both PPV groups throughout the shock phase. Creatinine levels were higher in both PPV groups (p = 0.04). The FM group was more hypercarbic and acidotic than the two PPV groups during the shock phase (p < 0.001). Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

Anesthesia for pediatric day-case dental surgery: a study comparing the classic laryngeal mask airway with nasal trachea intubation.

To study sevoflurane inhalation general anesthesia using the laryngeal mask airway (LMA) and nasal endotracheal (ET) intubation to maintain the airway in pediatric day-case dental surgery. A total of 171 children aged 2 to 7 years received elective day-case dental surgical procedure under general anesthesia. Children were randomly grouped into LMA groups (L) and nasal ET intubation group (N). In L groups, LMA was inserted after induction of anesthesia using 8% sevoflurane and were allowed to breathe spontaneously. Rocuronium and remifentanil were given intravenously during 8% sevoflurane induction by nasal ET intubation in the N group . The time of anesthetic induction, maintenance, recovery, surgical access, and bispectral index score were recorded. Postoperative nausea and vomiting and the incidence of adverse events during induction and recovery period were also recorded. The insertion time of LMA was significantly shorter than nasal ET (P < 0.05). The incidence of airway complications, the surgeons' access, and bispectral index were not different between the 2 groups. However, recovery time was significantly shorter in group L (P < 0.05). The incidence of sore throat and postoperative nausea and vomiting (P < 0.01) were much less in group L as well. Sevoflurane inhalation anesthesia through LMA is a safe and reliable method for pediatric day-case dental surgery.

Examination of Age‐dependent effects of fetal ethanol exposure on behavior, hippocampal cell counts, and doublecortin immunoreactivity in rats

Ethanol is known as a potent teratogen having adverse effects on brain and behavior. However, some of the behavioral deficits caused by fetal alcohol exposure and well expressed in juveniles ameliorate with maturation may suggest some kind of functional recovery occurring during postnatal development. The aim of this study was to reexamine age-dependent behavioral impairments in fetal-alcohol rats and to investigate the changes in neurogenesis and gross morphology of the hippocampus during a protracted postnatal period searching for developmental deficits and/or delays that would correlate with behavioral impairments in juveniles and for potential compensatory processes responsible for their amelioration in adults. Ethanol was delivered to the pregnant dams by intragastric intubation throughout 7-21 gestation days at daily dose of 6 g/kg. Isocaloric intubation and intact control groups were included. Locomotor activity, anxiety, and spatial learning tasks were applied to juvenile and young-adult rats from all groups. Unbiased stereological estimates of hippocampal volumes, the total number of pyramidal and granular cells, and double cortin expressing neurons were carried out for postnatal days (PDs) PD1, PD10, PD30, and PD60. Alcohol insult during second trimester equivalent caused significant deficits in the spatial learning in juvenile rats; however, its effect on hippocampal morphology was limited to a marginally lower number of granular cells in dentate gyrus (DG) on PD30. Thus, initial behavioral deficits and the following functional recovery in fetal-alcohol subjects may be due to more subtle plastic changes within the hippocampal formation but also in other structures of the extended hippocampal circuit. Further investigation is required.

Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

Objective To assess the role of nasal continuous positive airway pressure (CPAP) initiated at birth for prevention of death and bronchopulmonary dysplasia in very preterm infants.Design Systematic review.Data sources PubMed,...

ProSeal laryngeal mask airway and endotracheal tube in elderly hypertensive patients undergoing routine surgical procedures: A comparison of hemodynamic parameters

Background/PurposeThe effects of ProSeal laryngeal mask airway (PLMA) removal and tracheal extubation on cardiovascular responses were studied in elderly hypertensive patients in a randomized double-blind study. MethodsA total of 60 elderly hypertensive American Society of Anesthesiologists I–II patients were randomly allocated to two groups (n = 30 of each) for PLMA insertion or endotracheal intubation. A standardized anesthetic sequence was used for induction and maintenance of anesthesia. The two groups were then compared for pressor response at the time of extubation/PLMA removal. ResultsIn PLMA group, heart rate and rate pressure product increased during PLMA removal but remained elevated for only 3 minutes while mean arterial pressure remained elevated for only 2 minutes. The elevations of heart rate, mean arterial pressure, and rate pressure product were exaggerated in the extubation group and persisted for more than 5 minutes. No complication was observed in any patient and no difficulty was encountered in insertion of PLMA in any patient. ConclusionElderly hypertensive patients are at risk of exaggerated pressor response at the time of extubation. PLMA removal is associated with fewer hemodynamic changes than tracheal extubation and should be preferred wherever possible.

The influence of double cavity type laryngeal mask ventilation on hemodynamics for patients with geriatric anesthesia operation

Objective To analyze the influence of the dual chamber type laryngeal mask ventilation on hemodynamics in the treatment of elderly patients with general anesthesia operation.Methods 90 cases of operation under general anesthesia were randomly divided into 45 cases of tracheal intubation general anesthesia,laryngeal mask anesthesia group 45 cases,recording in two groups of patients before intubation immediately(T1),mean arterial pressure (MAP),heart rate,intubation immediately after the (T2) 3 min (T3),after intubation,tracheal extubation after immediate extubation after (T4) and 3 min (T5) mean arterial pressure (MAP),heart rate,epinephrine,norepinephrine level changes.The results of two groups of T,mean arterial pressure,heart rate (MAP,HR) there was no significant difference (all P ＞ 0.05).Two groups of T2,T3,T4,Ts mean arterial pressure,heart rate (MAP,HR),epinephrine,norepinephrine,laryngeal mask anesthesia group were significantly better than the intubation in general anesthesia group,with significant difference(all P ＜ 0.05).Results There was no significant difference in MAO,MR between the two groups at T1 (all P ＞ 0.05).The MAP,MR,epinephrine,norepinephrine of the laryngeal mask group were better than those of the intubation group at T2,T3,T4,T5 (all P ＜ 0.05).Conclusion Double cavity type laryngeal mask has the advantages of simple operation,operation for elderly patients with cardiovascular stimulation,ventilation reliability. Key words: Anesthesia, general; Laryngeal mask airway; Hemodynamics; Aged

The Usefulness of 3-Dimensional Virtual Simulation Using Haptics in Training Orotracheal Intubation

Objectives. Airway control is the most critical treatment. The most common and basic method of endotracheal intubation is orotracheal intubation. To perform accurate and rapid tracheal intubation, appropriate education and training are required. We developed the virtual simulation program utilizing the 3-dimensional display and haptic device to exercise orotracheal intubation, and the educational effect of this program was compared with that of the mannequin method. Method. The control group used airway mannequin and virtual intubation group was trained with new program. We videotaped both groups during objective structured clinical examination (OSCE) with airway mannequin. The video was reviewed and scored, and the rate of success and time were calculated. Result. The success rate was 78.6% in virtual intubation group and 93.3% in control group (P = 0.273). There was no difference in overall score of OSCE (21.14 ± 4.28 in virtual intubation group and 23.33 ± 4.45 in control group, P = 0.188), the time spent in successful intubation (P = 0.432), and the number of trials (P > 0.101). Conclusion. The virtual simulation with haptics had a similar effect compared with mannequin, but it could be more cost effective and convenient than mannequin training in time and space.

Prehospital non-drug assisted intubation for adult trauma patients with a Glasgow Coma Score less than 9

ObjectivesPrehospital airway management for adult trauma patients remains controversial. We sought to review the frequency that paramedic non-drug assisted intubation or attempted intubation is performed for trauma patients in Ontario,...

The Use of Disposable Laryngeal Mask Airway for Adenotonsillectomies

Tracheal intubation associated with airway operations can cause complications such as laryngospasm, bronchospasm and periods of reduced oxygen saturation. Such complications are frequently reported during adenotonsillectomies, a procedure that by nature increases the incidence of airway complications. The objective of this study was to compare the occurrence of respiratory problems during adenotonsillectomies while using either a disposable laryngeal mask airway (LMA) or an endotracheal tube (TT). We evaluated 204 pediatric patients undergoing general anesthesia for adenotonsillectomies. The patients were randomly allocated into either the tracheal intubation group (TT, n=100) or the laryngeal mask airway group (LMA, n=104). It was measured the level of oxygen saturation by pulse oximetry (SpO(2)) after the induction of anesthesia (SpO(2)-1), after establishing the operative field (SpO(2)-2), at the end of the surgical procedure (SpO(2)-3), three minutes after the removal of the contained breathing apparatus (SpO(2)-4) and upon admission to the post-anesthesia care unit (SpO(2)-5). All respiratory complications were recorded. The mean SpO(2) values and standard deviations for the TT and LMA groups were as follows: SpO(2)-1: 98.9±1.0 and 98.7±0.8 (p>0.25), SpO(2)-2: 97.4±1.0 and 94.9±4.3 (p<0.001), SpO(2)-3: 96.9±1.1 and 97.2±1.1 (p=0.037), SpO(2)-4: 91.7±9.0 and 95.2±2.2 (p<0.001) and SpO(2)-5: 94.0±2.1 and 95.8±2.6 (p<0.001), respectively. In the LMA group, 12 patients required some maneuvering to fix positioning and leaks during surgery. In four patients, the LMA had to be replaced with a TT. Respiratory complications were similar between groups. Performing adenotonsillectomies in pediatric patients using a LMA resulted in a lower intraoperative SpO(2), compared to using a TT. In some cases, the LMA had to be replaced with an endotracheal tube. Although the surgery may be performed with LMA, the use of a TT is preferred for safety.

Factors associated with difficult intubation in prehospital emergency medicine

When managing airways in a prehospital setting, emergency physicians have to deal with difficult intubation (DI), which increases morbidity and mortality. The primary goal of this study was to determine predictors of DI in the out-of-hospital field faced by the French physician-staffed Emergency Medical Service. The study was a prospective, observational study, including all consecutive patients intubated during a 30-month period. Patients having experienced standard intubation (two attempts or less) or DI (more than two attempts) were compared. Six hundred and ninety-four patients were included: 70 (11%) were classified as DI and 583 as standard intubations. Logistic regression showed that airways obstruction [odds ratio (OR), 4.1; 95% confidence interval (CI), 1.71-14.4], intubation on the floor (OR, 2.6; 95% CI, 1.04-6.6), and a hyoid-mental distance less than three fingers (OR, 2.3; 95% CI, 1.2-4.7) were independent predictors of DI. Immediate complications occurred in 89 patients (16%): 66 (11%) in the standard intubation group and 23 (31%) in the DI group (P<0.01). For prehospital orotracheal intubation, independent risk factors of DI are a mental-thyroid distance less than three fingers, a patient on the floor, and a superior airways obstruction. Anticipation of DI could result in fewer attempts, and fewer complications, as the rate of complication increases with the difficulty of intubation.

Comparison of the streamlined liner pharynx airway and endotreacheal intubation in the radic mastectomy under general anesthesia

Objective To compare the effects of streamlined liner pharynx airway(SLIPA) and endotracheal intubation in the radical mastectomy under general anesthesia,and to evaluate the efficacy and safety.Methods Sixty patients scheduled for radical mastectomy were randomly divided into 2 groups.SLIPA group( S,n =30 ) and endotracheal intubation group(T,n =30).The data were kept regarding the insertion time and successful rate,MAP,HR,BIS were recorded at 6 time points:before induction ( T0 ),during SLIPA incursion or trachel intubation ( T1 ),3min after intubation( T2 ),before extubation( T3 ),after extubation ( T4 ),3 min after extubation ( Ts ).Ppeak,PetCO2 and SpO2 were measured after successful airway placement at 10min,30min,60min and to observe intraoperative and postoperative throat complications.Results The time of endotracheal intubation group is significantly longer than SLIPA group (P ＜0.05).In group T,MAP and HR at T1,T2,T4,T5 were higer than at T0 and the same time points in group S(all P ＜ 0.05 ).No regurgitation and aspiration was found in two groups ( all P ＞ 0.05 ).The incidence of complicaton in group T is significantly higher than that in group S ( all P ＜ 0.05 ).Conclusion SLIPA is easier placement,safety and efficacy when it is used for the radical mastectomy under general anesthesia without significant influences on hemodynamics and fewer complications of throat after operation. Key words: Laryngeal mask ; Intubation, intratracheal; Anesthesia, general; Radical mastectomy

The curative effect of double-tube laryngeal mask on fast-track surgery in pediatric patients

Objective To explore the value of double-tube laryngeal mask in fast-track surgery in pediatric patients.Methods 60 pediatric patients scheduled for fast-track surgery were randomly divided into group of double-tube laryngeal mask (group A) and group of tracheal intubation (group B).At the same time points,mean arterial pressure (MAP),heart rate (HR),oxyhemoglobin saturation (SpO2),surgical duaration,awakening time,success rate of one-off tube placement and agitation after awakening were recorded in both groups before and after induction of anesthesia,1,3,and 5 min after placement of laryngeal mask or tracheal tube,and 5 min before and after removal of laryngeal mask or tracheal tube were recorded.A statistical analysis was conducted.Results No statistical difference was observed between the two groups in general conditions,MAP,HR and SpO2before and after induction of anesthesia,surgical duration,and success rate of one-off tube placement (P＞0.05).MAP and HR were significantly lower in group B than in group A after placement or removal of tube (P ＜ 0.05 or P ＜ 0.01).Conclusions Double-tube laryngeal mask is easy to apply and less invasive.It can be an ideal choice for anesthesia in fast-track surgery in pediatric patients if intraoperative ventilation monitoring is strengthened. Key words: Double-tube laryngeal mask; Pediatric patients; Fast-track surgery; Anesthesia

Postintubation hemodynamic effects of intravenous lidocaine in severe traumatic brain injury

BackgroundThe risks of intravenous (IV) lidocaine before rapid sequence induction (RSI) have become a great concern. No study has investigated the hemodynamic effects of IV lidocaine during endotracheal intubation in patients with severe traumatic brain injury. ObjectiveWe investigated whether the use of IV lidocaine before RSI was associated with postintubation hemodynamic changes in patients with severe traumatic brain injury. MethodsIn this retrospective cohort study, adults who presented with isolated traumatic brain injury and definite intracranial hemorrhage were included. Patients who presented with other major injuries received prehospital intubation, had initial mean arterial pressure (MAP) less than 70 mm Hg, and/or had incomplete medical records were excluded. ResultsA total of 101 patients (82.2% men; mean age, 48.6 ± 19.6 years) were enrolled. Forty-six patients received IV lidocaine in addition to RSI before intubation (group 1), and 55 received RSI without IV lidocaine before intubation (group 2). There were no significant intergroup differences in baseline characteristics, the number of RSI doses, or the RSI dose used, with the exception of sex, diagnosis of subarachnoid hemorrhage, and diagnosis of subdural hemorrhage. Our results demonstrated no significant intergroup differences in MAP changes or the proportion of patients with hypotension (MAP <70 mm Hg) after intubation. Intravenous lidocaine remained unrelated to significant hypotension after adjusting for variables by logistic regression analysis. ConclusionIntravenous lidocaine in addition to RSI before endotracheal intubation was not associated with significant hemodynamic changes in patients with severe traumatic brain injury.

Submandibular Sonography

The aim of this study was to evaluate the feasibility of sonography as a tool to measure the hyomental distance ratio and tongue size in obese patients with a large neck circumference. The hyomental distance ratio is a predictor of difficult laryngoscopy that may result in difficult intubation. Five obese and 7 morbidly obese adult patients with a history of either difficult or easy intubation had a submandibular sonographic examination performed in the supine position. The hyomental distance was measured while the head was placed in the neutral position and then in a hyperextended position, and the ratio of two distances (hyomental distance ratio) was calculated. Their tongue volumes were derived from multiplication of the midsagittal cross-sectional area of the tongue by its width obtained from transverse sonograms. The mean hyomental distance ratios ± SD in 6 patients with difficult intubation and 6 with easy intubation were 1.02 ± 0.01 and 1.14 ± 0.02 (P < .002), respectively. Tongue volumes did not differ statistically between the two groups: 137 ± 29 cm(3) (difficult intubation) and 168 ± 34 cm(3) (easy intubation). The mean body mass indices were 36.3 ± 6.0 and 43.2 ± 7.2 kg/m(2) in the difficult and easy intubation groups. The mean neck circumferences were 44.5 ± 7.4 and 46.8 ± 7.0 cm in the difficult and easy intubation groups. Sonography allows bedside measurements of the hyomental distance ratio and tongue size in morbidly obese patients. Preoperative assessment of the hyomental distance ratio may predict difficult laryngoscopy resulting in difficult intubation.