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7 results

  • Prehospital Surgical Cricothyrotomy in a Ground-Based 9-1-1 EMS System: A Retrospective Review

  • Al Lulla, Robert Dickson, Michael Wells, Matthew Gilbert, Kelly Rogers Keene, Casey Patrick
  • Journal:
    Prehospital and Disaster Medicine , First View
    Published online by Cambridge University Press:
    23 April 2024, pp. 1-4
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  • Background:

    Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system.

    Methods:

    This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated.

    Results:

    A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt.

    Conclusion:

    Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.

  • The Difficult Airway Redefined

  • Matthew B. Burgess, Steven G. Schauer, R. Lyle Hood, Robert A. De Lorenzo
  • Journal:
    Prehospital and Disaster Medicine / Volume 37 / Issue 6 / December 2022
    Published online by Cambridge University Press:
    09 November 2022, pp. 723-726
    Print publication:
    December 2022
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  • There is no all-encompassing or universally accepted definition of the difficult airway, and it has traditionally been approached as a problem chiefly rooted in anesthesiology. However, with airway obstruction reported as the second leading cause of mortality on the battlefield and first-pass success (FPS) rates for out-of-hospital endotracheal intubation (ETI) as low as 46.4%, the need to better understand the difficult airway in the context of the prehospital setting is clear. In this review, we seek to redefine the concept of the “difficult airway” so that future research can target solutions better tailored for prehospital, and more specifically, combat casualty care. Contrasting the most common definitions, which narrow the scope of practice to physicians and a handful of interventions, we propose that the difficult airway is simply one that cannot be quickly obtained. This implies that it is a situation arrived at through a multitude of factors, namely the Patient, Operator, Setting, and Technology (POST), but also more importantly, the interplay between these elements. Using this amended definition and approach to the difficult to manage airway, we outline a target-specific approach to new research questions rooted in this system-based approach to better address the difficult airway in the prehospital and combat casualty care settings.

  • Chapter 31 - Airway Management during CPR

  • from Section 2 - Airway Management: Clinical Settings and Subspecialties
  • Edited by Tim Cook, Michael Seltz Kristensen
  • Book:
    Core Topics in Airway Management
    Published online:
    03 October 2020
    Print publication:
    03 December 2020, pp 278-281

  • Summary

    The priorities of airway management during cardiopulmonary resuscitation are to minimise interruptions in chest compressions, to optimise blood flow and oxygen delivery to vital organs and to minimise delays in defibrillation if the initial rhythm is shockable. Thus, during the initial treatment of cardiac arrest, unusually, the circulation takes priority over the airway. Maintaining a patent airway will enable ventilation and oxygenation of the lungs, which becomes increasingly important after the first 3–4 minutes of sudden primary cardiac arrest (i.e. of cardiac cause). The optimal airway management strategy during cardiac arrest is uncertain. Many cardiac arrest patients are treated with multiple airway devices and this stepwise approach to airway management is difficult to study in controlled trials. The results of three recent randomised clinical trials suggest tracheal intubation should only be used in those settings with a high intubation success rate. While early oxygenation and ventilation are logically more important after asphyxial cardiac arrest existing resuscitation guidelines recommend the same sequence of actions regardless.

  • Chapter 19 - Multimodal Techniques for Airway Management

  • from Section 1 - Airway Management: Background and Techniques
  • Edited by Tim Cook, Michael Seltz Kristensen
  • Book:
    Core Topics in Airway Management
    Published online:
    03 October 2020
    Print publication:
    03 December 2020, pp 166-170

  • Summary

    As opposed to the simplistic promotion of one given technique or device, the multimodal airway management relies on the recognition that each individual approach may fail, that the maintenance of oxygenation during the procedure is a key point, that the prerequisites to the practical step of placing a tube in the trachea involve the knowledge of intelligent and intelligible algorithms and the previous acquisition of skills, with understanding of their foundations. An example of the ‘combination techniques’ using the specific advantages of one medical device to mitigate the limitations of another is the use of a videolaryngoscope to facilitate intubation with a flexible optical bronchoscope, which increases the ease and the success of the process during the clinical as well as the training phases. Other multimodal approaches such as the combination of bronchoscopy with the use of a supraglottic airway or with high flow nasal oxygen optimise the safety of the procedure by maintaining the delivery of oxygen. The multimodal approach is particularly useful for the anaesthesiologist and intensivist only occasionally exposed to the management of difficult airway situations. It improves high quality care of patients, education and training.

  • Feasibility and speed of insertion of seven supraglottic airway devices under simulated airway conditions

  • Oliver Robak, Marco Leonardelli, Konstantin Zedtwitz-Liebenstein, Kurt Rützler, Ernst Schuster, Sonia Vaida, Ramez Salem, Michael Frass
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 14 / Issue 6 / November 2012
    Published online by Cambridge University Press:
    11 May 2015, pp. 330-334
    Print publication:
    November 2012
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  • Objectives:

    Endotracheal intubation (ETI) is considered the gold standard for protecting the airway. Alternative devices for airway protection have been developed that can be used by untrained personnel, by those with less experience, and for when ETI is not possible. The main goals of our study were to evaluate the success rate and speed of insertion of different supraglottic airway devices and to determine whether the devices could be properly inserted under simulated critical conditions.

    Methods:

    Fifty medical students used an airway simulation trainer (Laerdal SimMan 3G) to assess the success rate and time used to insert seven different supraglottic airway devices under simulated physiologic and pathologic conditions in two different runs.

    Results:

    Although all airway devices could be inserted without problems, only the Combitube and the EasyTube could be successfully inserted in simulations of trismus, limited mobility of the cervical spine, or a combination of pathologic conditions such as trismus plus limited mobility of the spine and trismus plus tongue edema. The insertion time was significantly longer with LMA Unique, Fastrach, and I-Gel devices in both the first and second runs.

    Conclusion:

    The Combitube and the EasyTube were most easily inserted under simulated conditions such as trismus, limited mobility of the cervical spine, and combined pathologic conditions. Although all devices are useful for establishing an airway by nontrained medical students in standard simulations, we suggest that the Combitube and the EasyTube may offer advantages in difficult airway situations.

  • Chapter 22 - Bariatrics

  • from Section 3 - Specialties
  • Edited by Ian Calder, Adrian Pearce
  • Book:
    Core Topics in Airway Management
    Published online:
    10 January 2011
    Print publication:
    16 December 2010, pp 203-208

  • Summary

    Blind intubation techniques remain within the CCT training syllabus in the UK and can be classified into four groups. The four groups are blind oral or nasal, retrograde, light-guided, and intubating laryngeal mask. Blind nasal intubation remains a popular and successful technique in both anaesthetised and awake patients. The term retrograde intubation is a misnomer, and it should perhaps be termed guided blind intubation or translaryngeal intubation. Retrograde techniques are relatively contraindicated when neck anatomy is unfavourable, there is infection in the neck, a bleeding diathesis or gross glottic abnormality. Light-guided intubation has been described through a supraglottic airway, and a recently developed blind intubation device (BID) incorporates a supraglottic airway with oesophageal airway component and catheter with lighted tip. Intubation through a supraglottic airway is a useful effective technique and is included in Plan B for failed direct laryngoscopy in the Difficult Airway Society guidelines.

  • 4 - Management of the artificial airway

  • Edited by Iain Mackenzie
  • Book:
    Core Topics in Mechanical Ventilation
    Published online:
    14 October 2009
    Print publication:
    30 October 2008, pp 54-87

  • Summary

    A supraglottic airway is an airway that does not pass across the vocal cords, such as an oropharyngeal airway or a laryngeal mask. Intubation of the trachea with a cuffed tube is the only way to simultaneously provide a secure airway, repeated access to the trachea and ventilatory support. Unfortunately, the placement of an artificial airway, be it a supraglottic airway or an endotracheal or tracheostomy tube, bypasses many of the patient's natural defences and thus increases the risk of upper and lower airway colonization, aspiration and infection. For anything other than immediate life support, however, the airway needs to be secured with a cuffed endotracheal tube, or in some circumstances, a tracheostomy endotracheal intubation in the critically ill patient carries challenges over and above those encountered during routine anaesthesia airway management because of a number of additional complicating factors. A primary goal of airway management is oxygenation.