Requiring Emergency Intubation Research Articles

Video Laryngoscopy vs. Direct Laryngoscopy in Adult Patients with Difficult Airways Who Require Emergency Intubation

This review compares the efficacy of video laryngoscopy (VL) with that of direct laryngoscopy (DL) in adult patients with difficult airways who require emergency intubation. Intubation and laryngoscopy are critical in emergency settings, and VL has emerged as an alternative to DL, particularly in difficult airway cases and when performed by non-experienced practitioners. VL demonstrates advantages such as a wider field of view, enhanced glottic visibility, and higher first-pass success rates, particularly in difficult airway scenarios. However, it also presents limitations, including potential view obstruction and technical complexity. While the evidence points to the advantages of VL, particularly in achieving higher first-pass success rates and minimizing adverse events in adult patients with difficult airways, the inconclusive findings from randomized trials emphasize the importance of future research in refining practices and improving patient outcomes.

Peri-Intubation Cardiac Arrest, A Risk That Isn't Talked About Much.

Madam, Among the many high-risk treatments used on critically sick patients, tracheal intubation (TI) is one of the most preferred actions. Out of many risk factors associated with tracheal intubation, cardiac arrest (CA) is a rare, the most serious and least considered risk. In most studies, peri-intubation CA (PICA) is referred to as, when it occurs within 5-60 minutes following the intubation procedure (1). According to different studies, the estimated incidence of PICA varies from 1.8% to 3.1% (1,2,3). One would think that the rate of PICA would be higher outside of the hospital because the environment isn't as good as in the hospital and it's harder to get help if there are problems with intubation. Significantly, in a study performed by Jardine C G at al, the incidence rate (2.5) of out of hospital PICA is comparable to that reported earlier in hospitalized patients who required emergency intubation. According to Jardine C G at al, PICA is linked to several parameters that contribute to arterial oxygen desaturation during intubation (2). One such factor was being overweight (2,5). Arteriole desaturation happens much more rapidly in obese patients than in those of normal BMI because of their diminished oxygen reserves. A greater number of intubation attempts is also one of the main factors leading to PICA (1,3,4). Increased risk of peri-intubation CA was also seen in individuals with increased lactate levels (metabolic acidosis) compared to those without (1,5). Cardiogenic pulmonary ooedema patients are also at risk of PICA (1). Due to their inhibitory influence on catecholamine release caused by stress, neuromuscular blocking drugs like succinylcholine and rocuronium may cause cardiac arrest (2,4,5) PICA being a serious risk factor associated with TI, these preventative steps may significantly lower the likelihood of developing PICA. It should be made sure that successful intubation should be done at the first attempt to avoid risk of PICA. Ketamine and etomidate use should be preferred as they have favourable hemodynamic effect (3). PICA incidence may be decreased by using bag mask ventilation prior to intubation, which lessens the possibility of arterial desaturation. It is imperative that immediate resuscitation in case of PICA can reduce the number of deaths caused by it. Calculating shock index prior to intubation can help in improved management of the patient.

Clinical outcomes after a single induction dose of etomidate versus ketamine for emergency department sepsis intubation: a randomized controlled trial

Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2–0.3 mg/kg of etomidate or 1–2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], − 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021—Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001.

Tube-within-Tube Technique during Emergency Intubation for the Unanticipated Difficult Airway in Low-Resource Settings: A Case Report

Emergency intubation can pose numerous difficulties for an anaesthesiologist, especially in unpredictable situations. A crucial aspect in trauma cases with a low Glascow Coma Scale (GCS) is to promptly and safely secure the airway. Patient and environmental factors further complicate the intubation process. The survival rate of patients is closely linked to successfully establishing a patent airway. Factors that hinder intubation include limited ability to assess the airway, inadequate equipment and positioning, lack of backup, challenging or insufficient preoxygenation, presence of other life-threatening conditions, and the risk of aspiration. Familiarity with alternative techniques and utilization of all available aids can significantly reduce morbidity and mortality in settings with limited resources. The author presents a case report of a 26-year-old male patient with polytrauma and a head injury, presenting with a low GCS score, who required emergency intubation. This situation occurred unexpectedly in the triage area of the hospital. The ‘tube within tube’ intubation technique was effectively employed to achieve early and successful airway control in this resource-limited setting.

Near hanging: Profile, emergency management, and outcome

Background: Hanging is a very common mode of deliberate self-harm (DSH) used by patients. The spectrum of the triggers and methods used vary from play to place. Objective: To study the profile and outcome of near hanging. Methods and Materials: A retrospective descriptive study was conducted on patients presenting with near hanging to the Emergency Department (ED) between January 2017 and December 2018. Data were obtained from the triage registry of the ED. Results: During the study period, 1821 presented with DSH with 144 cases of near hanging. The mean age (SD) was 33 (12.9) years and the sex distribution was equal. One-tenth (9.7%) of them had a known psychiatric illness, whereas a quarter of them (22.9%) were under the influence of alcohol at the time of the incident. The most common material used was saree (52.8%). Eight patients were intubated elsewhere and referred to ED, whereas 79% required emergency intubation in ED, with the majority being hypoxic at arrival (84.7%). Of the 144 patients, 58.4% were admitted to the hospital, whereas 20.8% were discharged stable after 24 hours of observation. Among in-patients, the majority (92.7%) were discharged stable, 4.8% left against medical advice, and 2.3% died in the hospital. Conclusions: Hanging as a method of self-harm is used by a tenth of patients who present to the ED with DSH. Saree and rope are the most common materials used for this act. One-fifth of our patients had a bad outcome that was independent of most underlying baseline factors.

Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial.

Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation. A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival. Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294). While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.

Comparison of the predictive value of two international guidelines for safe discharge of patients with mild traumatic brain injuries and associated intracranial pathology

PurposeTo determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury.MethodsRetrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14–15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation.ResultsOf the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%.ConclusionThere was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline’s original study. At present, neither guideline can be recommended for implementation in the current or similar settings.

Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury

BackgroundEarly routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation.MethodsWe performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS).ResultsAmong 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P = 0.0144) in multivariate analyses.ConclusionTimely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

NCOG-30. AWAKE CRANIOTOMY FOR MENINGIOMA RESECTION: A STUDY ON THE SAFETY AND TOLERABILITY

Abstract Resection of intra-axial brain tumors under scalp block improves safety of surgery, permitting preservation of neurological function and early recovery. However, limited data is available on employing this anesthesia technique for extra-axial tumors particularly meningioma, raising concerns that it may not be feasible due to dural attachment of tumor causing intractable pain and discomfort. We retrospectively analyzed 17 patients who underwent AC for resection of meningioma at our hospital during last 5 years, employing non-probability consecutive sampling. Variables for demographics, and details of diagnosis and surgical procedure were recorded. Eleven of these cases had grade I meningioma, and 6 had grade II meningioma. The mean age of these patients was 45.8 ± 10.5 years. Seizures were the most common presenting complain (n = 7; 41.2%). Eleven patients (58.3%) had convexity meningioma, 4 (33.3%) had parasagittal meningioma and 1 each had a parafalcine and anterior skull-base meningioma. The mean duration of surgery was 180.8 ± 36.2 minutes and the median estimated blood loss was 450 ml (IQR: 225 ml – 737.5 ml). The mean length of stay in the hospital was 3.1 ± 1.3 days. Only 1 patient had a prolonged hospital stay of 7 days because of post-operative seizures. Simpson grade I resection was performed in 6 (41.7%) patients, and grade II resection in 10 (50%) patients. Deterioration in pre-operative neurological exam was not seen in any patient, and no one required emergency intubation, conversion of surgery to general anesthesia, or re-operations. We propose that AC does not pose any significant risk of intra-operative or post-operative pain during meningioma resection, particularly convexity and parasagittal meningioma, and can make surgery possible for patients who are high risk for, or are not willing to undergo general anesthesia.

Awake Craniotomy for Resection of Intracranial Meningioma: First Case Series From a Low- and Middle-Income Country.

IntroductionAwake craniotomy (AC) has emerged as a better modality for resection of intra-axial brain tumors. The advantages are not just related to the preservation of neurological function, but also include early recovery, short hospital stay and possibly lower costs. However, data on AC for meningioma resection is deficient, likely because of concerns related to intra-operative pain and blood loss.MethodsAll patients who underwent AC, using awake through-out technique for resection of meningioma, during the last five years, were included in the study. Non-probability consecutive sampling technique was employed. Variables for demographics, and details of diagnosis and surgical procedure were recorded. The outcomes measured were length of hospital stay, worsening of neurological function during surgery and significant intra-operative or post-operative pain.ResultsSeventeen patients underwent AC for resection of meningioma during the study period. Eleven of these were grade I meningioma, and six were grade II meningioma. The mean age was 45.8 ± 10.5 years. Presenting complaints were variable, with seizures being the most common (n = 7; 41.2%). The mean duration of surgery was 180.8 ± 36.2 minutes and median estimated blood loss was 450 ml (IQR: 225 ml - 737.5 ml). The mean length of stay in the hospital was 3.1 ± 1.3 days. Only one patient had a prolonged hospital stay of seven days, because of post-operative seizures. Eleven patients (58.3%) had convexity meningioma, 4 (33.3%) had parasagittal meningioma and 1 each had a parafalcine and anterior skull-base meningioma. Simpson grade I resection was performed in 6 (41.7%) patients, grade II resection in 10 (50%) patients, and grade III resection in 1 (5.9%) patient. None of our patients had deterioration in their neurological deficits after surgery and no one required emergency intubation, conversion of surgery to general anesthesia, or redo exploration.ConclusionAC may be considered a safe modality for surgical resection of convexity and parasagittal meningioma, with no significant risk of intra-operative or post-operative pain, although it requires more evidence. It can be offered to patients who are at higher risk, or are not willing to undergo general anesthesia. Ultimately, it might also be beneficial in terms of reducing overall costs.

Lung transplant after 6 months on ECMO support for SARS-CoV-2-induced ARDS complicated by severe antibody-mediated rejection

There have been a few reports of successful lung transplantation (LTx) in patients with SARS-CoV-2-induced acute respiratory distress syndrome (ARDS); however, all reports were with rather short follow-up. Here we...

The NIFty Method; Developing the “Neonatal Intubation Flowchart”

Introduction: When intubation is required during a neonatal emergency, it is imperative there are no delays in collecting equipment. Current practice is for the Intubation Assistant to gather intubation equipment with no memory adjuncts. This study aimed to develop a Neonatal Intubation Flowchart (NIF) and test whether it improves performance in equipment collection. Methodology: Using simulation, a control group (n = 21) was compared to an intervention group (utilizing prototype NIF 1) (n = 24), with both groups consisting of neonatal nurses, midwives, and junior and senior pediatric doctors. The simulation involved a neonate requiring emergency intubation and the participant was tasked to collect the intubation equipment. The outcomes measured were Percentage of Equipment Collected, Time to Collect Equipment, and Amount of Questions Asked. Following post-simulation feedback, the NIF 2 was developed. The same simulation was repeated to an intervention group (n = 28) which utilized NIF 2. Results: The NIF 2 displayed a significantly better Time to Collect Equipment compared to control and NIF 1 (Mean [M] = 64.3-102.0 and 150.8 s, respectively). The NIF 2 had a significantly better Percentage of Equipment Collected compared to the control and NIF 1 (M = 96%-59% and 87%, respectively). The NIF 2 demonstrated significantly less Amount of Questions Asked compared to the control and NIF 1 groups (Median = 0-1 and 2, respectively). Conclusion: The NIF 2 provides a significantly superior method to collect equipment, in a quicker time, with less distracting questions asked, compared to current practice.

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.

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.

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.

Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy

Stroke networks facilitate access to endovascular treatment (EVT) for patients with ischemic stroke due to large vessel occlusion. In this study we aimed to determine the safety of inter-hospital transfer and included all patients with acute ischemic stroke who were transferred within our stroke network for evaluation of EVT between 06/2016 and 12/2018. Data were derived from our prospective EVT database and transfer protocols. We analyzed major complications and medical interventions associated with inter-hospital transfer. Among 615 transferred patients, 377 patients (61.3%) were transferred within our telestroke network and had transfer protocols available (median age 76 years [interquartile range, IQR 17], 190 [50.4%] male, median baseline NIHSS score 17 [IQR 8], 246 [65.3%] drip-and-ship i.v.-thrombolysis). No patient suffered from cardio-respiratory failure or required emergency intubation or cardiopulmonary resuscitation during the transfer. Among 343 patients who were not intubated prior departure, 35 patients (10.2%) required medical interventions during the transfer. The performance of medical interventions was associated with a lower EVT rate and higher mortality at three months. In conclusion, the transfer of acute stroke patients for evaluation of EVT was not associated with major complications and transfer-related medical interventions were required in a minority of patients.

The practice and safety profile of endotracheal intubation in an emergency department: A single-center study in Shenzhen, China

Objectives: Endotracheal intubation is an essential skill of every emergency department clinician. The current practice of emergency intubation in the emergency departments in China and its safety is largely unknown. This study aimed at evaluating the practice and the safety profile of emergency intubation in an emergency department in Shenzhen. Methods: This study was of retrospective design. It was conducted in the emergency department of a university affiliated hospital. All patients requiring emergency intubation from 1 January 2017 to 30 June 2018 were recruited. Data on demographic and clinical characteristics of patients and characteristics of intubations were collected and analyzed. Results: A total of 128 patients were analyzed. Patients with spontaneous intracerebral hemorrhage were most common. Airway protection for patency was the most common indication of intubation. Most intubations were performed by emergency department staff with direct laryngoscopy. The first attempt success rate was 93.8%. Serious adverse events were rare. Conclusion: The practice of endotracheal intubation in the emergency department is in line with international ones. The safety profile is good. A national registry of emergency airway management is recommended.

Severe thermal injury of larynx in a child following accidental ingestion of hot tea

Thermal injury to the upper respiratory tract caused by aspiration of hot liquids resulting in laryngeal edema and subsequent obstruction of the airway is commonly not seen in the pediatric population. Unlike adults, children are more prone for subglottic injury, swelling and resulting obstruction of the airway due to the smaller size of the trachea and relatively large epiglottis. Examination of the airway with laryngoscopy hence should be recommended in all patients with inhalational and aspiration burn injury as it will help in guiding airway management and preventing development of complications. Authors report a case of a 3-year-old male child with accidental ingestion of just made hot tea. Upon presentation there was severe stridor and signs of respiratory distress requiring emergency intubation. Direct laryngoscopy revealed glottic edema and ulcer. Upper GI endoscopy showed erythematous arytenoids, esophagus and stomach showing few erythematous flat lesions. Chest radiographic examination showed bilateral para cardiac and perihilar inhomogeneous opacities suggestive of aspiration pneumonitis. The child was gradually weaned and extubated on day three of admission. Ingestion of hot liquids can cause airway and esophageal thermal burns. Rapid diagnosis and treatment are essential in management of inhalational and aspiration burn injury to reduce the morbidity, mortality and long-term sequelae in these patients. Children are more prone for burn accidents due to their curious and exploratory behavior and their inability to perceive the hazards. Since most of the pediatric burn accidents happen at home, parents should be offered education about prevention of burn and advised on how to manage and treat minor burn injuries and to watch for any warning signs in which case to rush to the nearest hospital.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial

IntroductionEmergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent...

Video Laryngoscopy vs. Direct Laryngoscopy.

Video Laryngoscopy vs. Direct Laryngoscopy.