Video-stylet vs. channeled hyperangulated videolaryngoscope: Efficacy in simulated Ludwig's angina randomized cadaver trial.

INTRODUCTION: Ludwig's angina (LA) is a life-threatening infection that can affect the floor of the mouth and neck, potentially causing serious airway obstruction. In such cases, rescue airway management and oxygenation can be challenging due to swelling of the mouth floor, trismus, and limited mouth opening. The aim of this study was to assess the efficacy of the Trachway video-stylet (VS) and Pentax AWS hyperangulated videolaryngoscope with channel (HAVL-C) compared to the standard geometric video-laryngoscope (SGVL, Macintosh 3, Trachway) in simulating Ludwig's angina with cadavers. METHODS: Three fresh frozen cadavers were prepared with varying degrees of difficulty to simulate the airway conditions of patients with LA, including mouth floor swelling, restricted mouth opening, and trismus. Fifty-five second-year resident physicians from various specialties participated in the study and received training in airway management using SGVL, VS, and HAVL-C devices. Participants were randomly assigned to intubate simulated LA with cadavers using the three devices in a random order, and intubation times and success rates were recorded. Participants also rated the difficulty of intubation using a visual analogue scale (VAS) score. The primary outcome assessed the first-pass intubation success or failure, while the secondary outcomes measured the intubation time and subjective difficulty using a visual analogue scale with different laryngoscopes. RESULTS: The success rates for intubation within 90 s were 40% for SGVL, 82% for VS, and 76% for HAVL-C. VS and HAVL-C had significantly higher success rates than SGVL, with hazard ratios of 3.4 and 2.7, and 95% confidence intervals (CI) of 2.0-5.7 and 1.6-4.6, p < 0.001, respectively. The odds ratios of successful intubation for VS and HAVL-C were 8.1 and 6.3, respectively, with a 95% CI of 3.7-17.8 and 2.4-16.7, p < 0.001, compared to SGVL. The VAS score was significantly correlated with intubation success rate and time. CONCLUSIONS: In cases of LA, the use of VS and HAVL-C is preferable over SGVL. These findings suggest that using VS and HAVL-C can improve intubation success rates and reduce intubation time in patients with LA.

The evaluation of a better intubation strategy when only the epiglottis is visible: a randomized, cross-over mannequin study.

BACKGROUND: The Cormack-Lehane (C-L) grade III airway is considered to be a challenging airway to intubate and is associated with a poor intubation success rate. The purpose of this study was to investigate whether the holding position, shapes, bend angles of the endotracheal tube (ET) and the stylet-assisted lifting of the epiglottis could improve the success rate of intubation. METHODS: Thirty-two participants, 26 physicians, 2 residents, and 4 nurse practitioners, with 12.09 ± 5.38 years of work experience in the emergency department and more than 150 annual intubation events, were enrolled in this randomized, cross-over mannequin study. We investigated the effects of straight-to-cuff ET shapes with 35° and 50° bend angles, banana-shaped ET with longitudinal distances of 28 cm and 26 cm, two methods of holding the ET (either on the top or in the middle), and lifting or not the epiglottis, on the intubation duration, its success rate, and its subjective difficulty. The aim of the study is to provide optimized intubation strategies for difficult airway with C-L IIb or III grades, when the inlet of the trachea cannot be visualized. RESULTS: The two groups that lifted the epiglottis using the stylets, in bend angles of 35° and 50°, had the shortest duration of intubation (23.75 ± 14.24 s and 20.72 ± 6.90 s, hazard ratios 1.54 and 1.85 with 95% confidence intervals [95% CI] of 1.01-2.34 and 1.23-2.78, respectively) and a 100% success rate in intubations. In the survival analysis, lifting of the epiglottis was the only significant factor (p < 0.0001, 95% CI 1.34-2.11) associated with the success rate of intubation. CONCLUSIONS: The use of the epiglottic lift as an adjunctive technique can facilitate the intubation and improve its success rate without increasing procedure difficulty, in C-L III airway, when only the epiglottis is seen. TRIAL REGISTRATION: ClinicalTrials Registry ( https://clincaltrials.gov , identifier NCT03366311).

Review of Emergency Response Management of 33 Major Burn Victims of the Formosa Fun Coast Dust Explosion Disaster in a Regional Hospital Without Burn Units.

BACKGROUND: The Formosa Fun Coast Dust Explosion is one of the major national disasters in Taiwan. The Taipei City Hospital (TCH), a regional hospital without a burn unit, received 33 patients out of 499 casualties in the initial response period. This retrospective study aimed to review the primary response of TCH and the outcome and mortality of the patients who were initially managed at TCH. METHODS: Basic profi les, total body surface area (TBSA) with burn injury, facial burn injury, vital signs, laboratory data, intubation rate and clinical outcomes, such as urine output and mortality, were analyzed. Moreover, the emergency department (ED) response faculties, who were involved in the initial response, were interviewed about the critical decision-making processes during the patient surge in the ED. RESULTS: The average initial estimated TBSA with burn injury in ED was 34.2%, and the average final TBSA assessed in the intensive care unit was 41.0%. The patients with facial burn injury were 38.7%, and the intubation rate was 22.6%. When comparing the result of TCH to the patient group transferred directly to Chang Gung Memorial Hospital (CGMH), and the group received by CGMH from other hospital, the mortality rate was 0.0, 5.7, 9.1%; and the delayed intubation rate was 3.0, 14.3, 27.3%, respectively. The key elements for effi cient initial response were the multidisciplinary response team cooperated as a production line, using the clipboards for orders recordings, and the plastic surgeons ED-operating room (OR) direct transferring. CONCLUSIONS: Regarding airway complications, and mortality, patients who were initially managed in TCH had comparable results with patients directly sent to the burn centers. This study supports the notion that immediate resuscitation in multiple level of hospitals, even without burn units but with adequate recruited response personnel, provided the best chance for the survival of casualties during such national disasters.