EM Airway

BACKGROUND: The recommended rocuronium dose for rapid sequence intubation is 1.0 mg/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. METHODS: 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...

OBJECTIVE: Rapid sequence intubation (RSI) is associated with a number of complications that can increase morbidity and mortality. Among RSI agents used to blunt awareness of the procedure and produce amnesia, ketamine is unique in its classification as a dissociative agent rather than a central nervous system depressant. Thus, ketamine should have a lower risk of peri-RSI hypotension because of the minimal sympatholysis compared with other agents. Recent recommendations include the use of ketamine for RSI in hemodynamically unstable patients...

OBJECTIVE: Recent drug shortages have required the occasional replacement of etomidate for endotracheal intubation (ETI) by helicopter emergency medical services (HEMS), with ketamine. The purpose of this study was to assess whether there was an association between ketamine vs etomidate use as the main ETI drug, with hemodynamic or clinical (airway) end points. METHODS: This retrospective study used data entered into medical records at the time of HEMS transport...

BACKGROUND: In the trauma population, ketamine is commonly used during rapid sequence induction. However, as ketamine has been associated with important side effects, this study sought to compare in-hospital mortality in trauma patients after induction with ketamine versus other induction agents. METHODS: We retrospectively identified adult trauma patients intubated in the pre-hospital phase or initially in the trauma bay at two urban level-1 trauma centers during a 2-year period using local trauma registries and medical records...

Some patients are agitated and unable to tolerate conventional preoxygenation methods, including face mask oxygen or noninvasive positive-pressure ventilation. Sedation with ketamine for preoxygenation, also known as delayed sequence intubation, is a technique that can be used to achieve preoxygenation in this patient population. No complications of delayed sequence intubation have previously been reported. A 60-year-old woman presented with acute hypoxic respiratory failure. Despite application of high-flow oxygen (60 L/min) with a nonrebreather face mask, her oxygen saturation remained at 93%...

No abstract text is available yet for this article.

BACKGROUND: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. METHODS: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation...

STUDY OBJECTIVE: It is unclear whether laryngoscopy using a standard-geometry blade shape, able to obtain both direct and indirect views, is associated with different first-attempt success or adverse events during emergency intubation compared with using a hyperangulated blade capable of indirect laryngoscopy only. We sought to compare first-attempt intubation success between patients intubated with a standard geometry video laryngoscope versus a hyperangulated video laryngoscope. METHODS: We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018...

The use of laryngeal mask airways with morbidly obese patients remains controversial. A recent legal case involving the use of a laryngeal mask airway with a morbidly obese patient who aspirated during the anesthetic found the anesthesia providers negligent. We sought evidence examining the use of laryngeal mask airways with obese patients undergoing surgery. One Cochrane systematic review and a randomized controlled trial met our inclusion criteria. Subjects received general anesthesia with a laryngeal mask airway...

BACKGROUND: Class III obese patients have altered respiratory mechanics, which are further impaired in the supine position. The authors explored the hypothesis that preoxygenation in the 25 degrees head-up position allows a greater safety margin for induction of anesthesia than the supine position. METHODS: A randomized controlled trial measured oxygen saturation and the desaturation safety period after 3 min of preoxygenation in 42 consecutive (male:female 13:29) severely obese (body mass index > 40 kg/m) patients who were undergoing laparoscopic adjustable gastric band surgery and were randomly assigned to the supine position or the 25 degrees head-up position...

OBJECTIVE: Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies. METHODS: We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM...

OBJECTIVE: To determined whether the implementation of an intubation management protocol leads to the reduction of intubation-related complications in the intensive care unit (ICU). DESIGN: Two-phase, prospective, multicenter controlled study. SETTING: Three medical-surgical ICUs in two university hospitals. PATIENTS: Two hundred three consecutive ICU patients required 244 intubations. INTERVENTIONS: All intubations performed during two consecutive phases (a 6-month quality control phase followed by a 6-month intervention phase based on the implementation of an ICU intubation bundle management protocol) were evaluated...

BACKGROUND: Patients with acute hypoxemic respiratory failure are at risk for life-threatening complications during endotracheal intubation. Preoxygenation might help reduce the risk of hypoxemia and intubation-related complications. This network meta-analysis summarizes the efficacy and safety of preoxygenation methods in adult patients with acute hypoxemic respiratory failure. METHODS: We searched PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2019 for randomized controlled trials (RCT) that studied the use of conventional oxygen therapy (COT), high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and HFNC and NIV as preoxygenation before intubation in patients with acute hypoxemic respiratory failure...

BACKGROUND: Periintubation hypotension is associated with poor outcomes in the critically ill. We aimed to determine if an admixture of ketamine and propofol for emergent endotracheal intubation in critically ill patients was superior to etomidate. Primary endpoint was the change in mean arterial pressure from baseline to 5 minutes postdrug administration. METHODS: Emergent-use, stratified (shock status and unit type), multiunit, randomized, parallel-group superiority clinical trial was conducted at a tertiary academic medical center...

OBJECTIVES: External laryngeal manipulation (ELM) is commonly used to facilitate laryngeal view during direct laryngoscopy. We evaluated the effectiveness of the newly modified bimanual laryngoscopy, which involves a direct guidance of an assistant's hand by a laryngoscopist, to optimize laryngeal exposure during direct laryngoscopy compared with conventional bimanual laryngoscopy. METHODS: A total of 78 adult patients were included. Patients were randomly allocated to 1 of 2 groups: group C (ELM using conventional bimanual laryngoscopy) or group M (ELM using the modified bimanual laryngoscopy)...

STUDY OBJECTIVE: We perform a videographic analysis of external laryngeal manipulation (ELM) by novice intubators using a direct laryngoscopic imaging system and a validated means of assessing laryngeal view (percentage of glottic opening [POGO] score). METHODS: Nine first-year emergency medicine residents performed a total of 484 laryngoscopies during a 1-year study period, of which 271 were videotaped. Of this convenience sample, cases were included in the study if the initial laryngeal view had a POGO score of less than 50% and the quality of video imaging permitted POGO scoring before and after application of ELM...

The displacement of the larynx in the three specific directions (a) posteriorly against the cervical vertebrae, (b) superiorly as possible, and (c) slightly laterally to the right have been reported and named the "BURP" maneuver. We evaluated the efficacy of the BURP maneuver in improving visualization of the larynx. Six hundred thirty patients without obvious malformation of the head and neck participated in this study. We divided the degree of visualization of the larynx using laryngoscopy into five grades and compared the visualization of the larynx using the BURP maneuver with that of laryngoscopy with and without simple laryngeal pressure ("Back")...

STUDY OBJECTIVE: To determine the improvement in laryngoscopic view obtained using both the Macintosh and Miller blades by applying optimal external laryngeal manipulation (OELM). DESIGN: Prospective, with each patient serving as his or her own control. SETTING: Inpatient operating rooms of a University Medical Center. PATIENTS: 181 informed and consenting adult nonpregnant patients requiring general anesthesia and tracheal intubation...

No abstract text is available yet for this article.

OBJECTIVE: Head-up positioning for preoxygenation and ramping for morbidly obese patients are well-accepted techniques, but the effect of head-up positioning with full torso elevation for all intubations is controversial. We compared first-pass success, adverse events, and glottic view between supine (SP) and nonsupine (NSP) positioning for emergency department (ED) patients undergoing orotracheal intubation. METHODS: We performed a retrospective analysis of prospectively collected data for ED intubations over a 2-year period from 25 participating centers in the National Emergency Airway Registry (NEAR)...