Airway Management

INTRODUCTION: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. METHODS: The Life-Saving Intervention (LSI) study is a prospective, institutional review board-approved, multicenter trial examining LSIs performed in the prehospital combat setting...

OBJECTIVE: The use of surgical cricothyrotomy (SC) in the prehospital setting is controversial, and the need to teach this procedure to paramedics and intermediate emergency medical technicians remains unclear. The purpose of this study is to define the efficacy, complication rate, and overall survival after SC performed in the prehospital setting. METHODS: In our region, emergency medical technicians receive training in this technique using an animal model with bi-annual updates required...

Emergent cricothyrotomy is an infrequently performed procedure used in the direst of circumstances on the most severely injured patients. Austere environments present further unique challenges to effective emergency medical practice. Recently, military trauma registry data were searched for the frequency of cricothyrotomy use and success rates during a 22-month period. These data revealed that cricothyrotomy performed in the most rigorous austere environment (ie, battlefield) had many successes, but also a large number of failed (33%) attempts by medics owing to many factors...

Although the surgical cricothyrotomy procedure is used on combat casualties in the most challenging environments, we are unaware of any published report in the United States of surgical cricothyrotomy performed in a wilderness recreational setting. We describe a 31-year-old male rock climber who fell 24.4 m (80 feet), sustaining serious injuries and requiring rescue from the base of the cliff by a cave/cliff rescue team. Ultimately, a surgical cricothyrotomy proved necessary because of ongoing oropharyngeal bleeding, facial fractures creating an unstable airway, and the need to place the patient in the litter...

Managing the airway does not mean intubation, it means managing the airway. Allowing a patient to breathe on their own with appropriate positioning, bag-valve ventilation and blind insertion devices are all airway management options. The surgical cricothyrotomy is a rare and life-saving procedure when managing patients who are in a "can't intubate, can't ventilate" situation. These patients will die without aggressive and rapid intervention. While not all surgical cricothyrotomies provide a definitive airway, the needle cricothyrotomy is an ineffective means for ventilation and its use is discouraged...

OBJECTIVE: To discuss the role of the King LT reusable supraglottic airway in emergency airway management. DESIGN: Retrospective case series review. SETTING: Tertiary academic medical facility. PATIENTS: We studied patients who presented to the emergency trauma center having undergone intubation at an outside facility or at the scene of the incident. The otolaryngology service was consulted for definitive management of the airway...

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Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management (CRM) involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of US dental offices per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia as well as the treatment of medical urgencies/emergencies...

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Part 1 in this series on emergency airway management focused on basic and fundamental considerations for supplying supplemental oxygen to the spontaneously breathing patient and utilizing a bag-valve-mask system including nasopharyngeal and oropharyngeal airways to deliver oxygen under positive pressure to the apneic patient. This article will review the evolution and use of advanced airway devices, specifically supraglottic airways, with the emphasis on the laryngeal mask airway, as the next intervention in difficult airway and ventilation management...

Patients requiring airway management in the emergency department present an enormous challenge. It requires not only a firm concept of techniques for securing the airway but also of dealing with the potential difficult airway (DA) in which establishing a definite airway is not possible with techniques routinely used. This article highlights the importance of recognition and management of the DA in emergent situations. Both awake and nonawake intubation are discussed, and indications and guidelines are given for the use of nonsurgical and surgical airway interventions...

Supraglottic airway devices (SAD) play an important role in the management of patients with difficult airways. Unlike other alternatives to standard tracheal intubation, e.g. videolaryngoscopy or intubation stylets, they enable ventilation even in patients with difficult facemask ventilation and simultaneous use as a conduit for tracheal intubation. Insertion is usually atraumatic, their use is familiar from elective anaesthesia, and compared with tracheal intubation is easier to learn for users with limited experienced in airway management...

Advances in emergency airway management have allowed intensivists to use intubation techniques that were once the province of anesthesiology and were confined to the operating room. Appropriate rapid-sequence intubation (RSI) with the use of neuromuscular blocking agents, induction drugs, and adjunctive medications in a standardized approach improves clinical outcomes for select patients who require intubation. However, many physicians who work in the ICU have insufficient experience with these techniques to adopt them for routine use...

PURPOSE: The King LT(S)-D laryngeal tube (King LT) has gained popularity as a bridge airway for pre-hospital airway management. In this study, we retrospectively reviewed the use of the King LT and its associated airway outcomes at a single Level 1 trauma centre. METHODS: The data on all adult patients presenting to the Mayo Clinic in Rochester, Minnesota with a King LT in situ from July 1, 2007 to October 10, 2012 were retrospectively evaluated. Data collected and descriptively analyzed included patient demographics, comorbidities, etiology of respiratory failure, airway complications, subsequent definitive airway management technique, duration of mechanical ventilation, and status at discharge...

Patients requiring emergency airway management are at great risk of hypoxemic hypoxia because of primary lung pathology, high metabolic demands, anemia, insufficient respiratory drive, and inability to protect their airway against aspiration. Tracheal intubation is often required before the complete information needed to assess the risk of periprocedural hypoxia is acquired, such as an arterial blood gas level, hemoglobin value, or even a chest radiograph. This article reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation...

Airway management is of major importance in prehospital emergency care. Bag-valve mask (BVM) ventilation and endotracheal intubation (ETI) have been shown to be difficult, especially when caregivers are inexperienced. Alternative methods have been studied, and supraglottic devices have been shown to provide reasonable ease of placement and effective ventilation in manikin studies and anaesthetised patients. First responders (FR) are employed by many emergency medical services (EMS) to shorten initiation of emergency care, and they are trained to provide basic CPR including BVM and use of automated external defibrillators (AED) in case of out-of-hospital cardiac arrest (OCHA)...

Although endotracheal intubation is commonly performed in the hospital setting, it is not without risk. In this article, we review the impact of endotracheal intubation on airway injury by describing the acute and long-term sequelae of each of the most commonly injured anatomic sites along the respiratory tract, including the nasal cavity, oral cavity, oropharynx, larynx, and trachea. Injuries covered include nasoseptal injury, tongue injury, dental injury, mucosal lacerations, vocal cord immobility, and laryngotracheal stenosis, as well as tracheomalacia, tracheoinnominate, and tracheoesophageal fistulas...

Airway management complications causing temporary patient harm are common, but serious injury is rare. Because most airways are easy, most complications occur in easy airways: these complications can and do lead to harm and death. Because these events are rare, most of our learning comes from large litigation and critical incident databases that help identify patterns and areas where care can be improved: but both have limitations. The recent 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society provides important detailed information and our best estimates of the incidence of major airway complications...

OBJECTIVE: We characterized out-of-hospital airway management interventions, outcomes, and complications using the 2012 NEMSIS Public-Release Research Data Set containing almost 20 million Emergency Medical Services activations from 40 states and two territories. We compared the outcomes with a previous study that used 2008 NEMSIS data containing 16 states with 4 million EMS activations. METHODS: Patients who received airway management interventions including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and surgical) were identified...

OBJECTIVE: The objective of this study was to characterize pediatric out-of-hospital airway management interventions, success rates, and complications in the United States using the 2012 National Emergency Medical Services Information System (NEMSIS) dataset. METHODS: In 2012, NEMSIS collected data from Emergency Medical Services (EMS) encounters in 40 states. We included all patients less than 18 years of age and identified all patients who had airway interventions including endotracheal intubation (ETI), bag-valve-mask ventilation (BVM), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) and alternate airways (Combitube, King LT, Laryngeal Mask Airway (LMA), esophageal obturator airway, and cricothyroidotomy)...

BACKGROUND: Supraglottic airways (SGAs) have an established role in airway management of difficult airways in both adults and children. However, there are limited data regarding the use of SGAs for primary airway management in children. The aim of this study is to assess the success rates and adverse events related to the use of SGAs for primary airway management during anaesthesia in children with difficult airways. METHODS: A retrospective analysis of SGA use for primary airway management in the difficult airway population in a single centre over a 4-yr period was performed...