Airway management in unusual environments.

Critically injured patients are often found in unusual positions and environments which can hinder the first responder's access to render necessary care. This work describes the use of the videolaryngoscope in airway management of the critically injured patient under unusual conditions.

Using the intubating laryngeal tube in a manikin - user evaluation of a new airway device.

This work describes the use of a new intubation device, the intubating laryngeal tube (iLTA) as developed by Boedeker. Emergency Department residents and staff from the University of Nebraska Medical Center performed intubations using the Laerdal Difficult Airway Trainer Manikin(TM). The participants' perceived value of the intubating laryngeal tube as well as its efficacy in intubation performance were measured and found to be highly favorable.

Endotracheal intubation with a traditional videolaryngoscope blade versus an integrated suction blade in a hemorrhagic airway cadaver model.

Lightly embalmed hemorrhagic cadaver models and the Storz CMAC videolaryngoscope fitted with either an integrated suction blade vs. a traditional blade were used to determine efficacy of the instruments in hemorrhagic airway intubation. Significant differences were found between the devices in intubation success rates of the viscosity saliva and frothy blood models, as well as a significant difference in intubation times in the frothy blood model. Feedback provided by the study participants indicated preference for the integrated video suction blade in hemorrhagic airway intubation.

A demonstration of the Storz C-CAM in endoscopic imagery projection for far forward battlefield telemetric support and training.

Airway management skills are essential for healthcare providers within military and civilian settings. To maintain competency in these skills, it is crucial for the provider to have opportunities for review and retraining. Virtual airway training or telementoring can be an effective means to fulfilling these requirements for healthcare providers located in remote sites. The projection of high quality imagery to far forward locations is essential for health care practitioners in the provision of telemedicine and distance training. The Storz C-CAM was developed to interface with existing endoscopy equipment to facilitate implementation of telemetric devices in remote locations. This work describes the use of the Storz C-CAM in providing medical device training to deployed medical personnel at a far forward location.

Nasotracheal intubation in a difficult airway using the Storz C-MAC Videolaryngoscope, the Boedeker Bougie endotracheal introducer, and the Boedeker curved forceps.

Airway management has multiple indications for nasotracheal intubation. In this study, we focus on its indication in difficult airways. This work describes a modified procedure of nasotracheal intubation using the new Storz CMAC® Videolaryngoscope, the malleable Boedeker Bougie and the curved Boedeker Forceps in the intubation of a difficult airway manikin.

Performance comparison of laryngoscopy and suction techniques in a hemorrhagic airway manikin simulator: direct laryngoscopy with Yankauer vs. Storz CMAC with attached suction tip.

Airway management of the hemorrhagic airway can be a difficult skill to master as trainee exposure to this difficult airway may be limited. In this study, we employed a hemorrhagic airway simulator along with a videolaryngoscope and the Storz Boedker-Doerges (BD) suction blade. These devices provided improved intubation performance in this model with respect to traditional direct laryngoscope (DL) and VL blades. This study shows that use of a hemorrhagic simulator could be an effective and valuable training tool in difficult airway intubation training.

A comparison of an integrated suction blade versus a traditional videolaryngoscope blade in the endotracheal intubation of a hemorrhagic cadaver model - a pilot study.

In this pilot study, we evaluated two types of videolaryngoscope blades (integrated suction vs. traditional) with the Storz CMAC videolaryngoscope in the intubation of a lightly embalmed hemorrhagic cadaver model. No significant differences were found between the devices in the success rates for the intubations. The study subjects indicated a preference for the integrated suction blade in hemorrhagic airway intubation.

Use of a malleable bougie and curved forceps with videolaryngoscopy in airway management training in a cadaver model - a pilot study.

The wider angle of view of videolaryngoscopy versus standard direct laryngoscopy requires an assessment of the adjunctive devices used to facilitate intubation. In this study, subjects performed malleable bougie-assisted intubation and curved forceps removal of a glottic foreign body using videolaryngoscopy on a lightly embalmed cadaver and completed a post-procedure questionnaire. All subjects valued access to the malleable bougie available at their hospitals and 82% valued access to the curved forceps. Malleable bougie and curved forceps seem well-suited to facilitate videolaryngoscopic airway management.

Combined intubation training (simulated and human) for 4th year medical students: the Center for Advanced Technology and Telemedicine airway training program.

The video laryngoscope is a useful tool in intubation training as it allows both the trainer and the student to share the same view of the airway during the intubation process. In this study, the Center for Advanced Technology and Telemedicine's airway training program employed videolaryngoscopy (VL) in teaching both simulated (manikin) and human intubation. The videolaryngoscope statistically improved the glottic view in both the standard and difficult manikin airways when compared to that with standard (direct) laryngoscopy. The success rate in simulated difficult airway intubation was significantly improved using VL. With human intubation training, there was statistically significant improvement in airway views using VL and a 97.5% intubation success rate. The enhanced view of the videolaryngoscope in airway intubation facilitates the learning process in performing both simulated and human intubation, making it a powerful tool in intubation training.

Improving fiberoptic intubation with a novel tongue retraction device.

This study examined the utility of a novel tongue retractor created with a wider working blade and a more ergonomic curve to provide jaw lift and tongue management with one hand during intubation. Anesthesia providers participated in simulated intubation of a difficult manikin using the novel tongue retractor with the Bonfils video fiberscope. Results show that the tongue retractor improved placement success and was well received by the study participants.

Macrophage activation in stellate ganglia contributes to lung injury-induced arrhythmogenesis in male rats.

AIM: Patients suffering from acute lung injury (ALI) are at high risk of developing cardiac arrhythmias. We hypothesized that stellate ganglia (SG) neural inflammation contributes to ALI-induced arrhythmia. METHODS: We created an ALI rat model using a single tracheal instillation of bleomycin (2.5 mg/kg), with saline as a sham control. We recorded ECGs by implanted radiotelemetry in male bleomycin and sham rats treated with and without oral minocycline (20 mg/kg/d), an anti-inflammatory drug that inhibits microglia/macrophage activation. The SG neuronal excitability was assessed by electrophysiology experiments. RESULTS: ECG data showed that bleomycin-exposed rats exhibited significantly more spontaneous premature ventricular contractions (PVCs) from 1- to 3-week post-induction compared with sham rats, which was mitigated by chronic oral administration of minocycline. The bleomycin-exposed rats displayed a robust increase in both the number of Iba1-positive macrophages and protein expression of interferon regulatory factor 8 in the SG starting as early at 1-week post-exposure and lasted for at least 4 weeks, which was largely attenuated by minocycline. Heart rate variability analysis indicated autonomic imbalance during the first 2-week post-bleomycin, which was significantly attenuated by minocycline. Electrical stimulation of the decentralized SG triggered more PVCs in bleomycin-exposed rats than sham and bleomycin + minocycline rats. Patch-clamp data demonstrated enhanced SG neuronal excitability in the bleomycin-exposed rats, which was attenuated by minocycline. Co-culture of lipopolysaccharide (LPS)-pretreated macrophages with normal SG neurons enhanced SG neuronal excitability. CONCLUSION: Macrophage activation in the SG contributes to arrhythmogenesis in bleomycin-induced ALI in male rats.

Improving rigid fiberoptic intubation: a comparison of the Bonfils Intubating Fiberscope with a novel modification.

BACKGROUND: The Bonfils intubating fiberscope has a limited upward tip angle of 40 degrees and requires retromolar entry into the hypopharynx. These factors may make its use less desirable when managing the difficult airway because most anesthesia providers are well versed in midline oral intubation rather than the lateral retromolar approach. The Center for Advanced Technology and Telemedicine at the University of Nebraska Medical Center has developed a novel fiberscope with a more anterior 60 degrees curve to allow for easier midline insertion and intubation. The objective of this work was to evaluate the novel fiberscope, in comparison to the Bonfils intubating fiberscope, in terms of use and function in difficult airway intubation. METHODS: Twenty-two anesthesia providers participated in simulated intubations of a difficult airway mannequin to compare the Bonfils intubating fiberscope with the novel curved Boedeker intubating fiberscope. The intubations were assessed based upon the following variables: recorded Cormack Lehane airway scores, requests for cricoid pressure, time to intubation, number of intubation attempts and success or failure of the procedure. RESULTS: Participants using the Bonfils fiberscope recorded an average Cormack Lehane (CL) airway score of 1.67 +/- 1.02 (median = 1); with the novel fiberscope, the recorded average airway grade improved to 1.18 +/- 0.50 (median = 1). The difference in airway scores was not statistically significant (p = 0.34; Fishers Exact Test comparing CL grades 1&2 vs. 3&4). There was, however, a statistically significant difference in intubation success rates between the two devices. With the Bonfils fiberscope, 68% (15/22) of participants were successful in intubation compared to a 100% success rate in intubation with the novel fiberscope (22/22) (p = 0.008). After the intubation trial, the majority of participants (95%) indicated a preference for the novel fiberscope (n = 20). CONCLUSIONS: With this data, we can infer that the novel fiberscope curvature appears to improve or maintain the quality of an intubation attempt (airway score, cricoid pressure requirement, intubation time, number of attempts, placement success). The data indicate that the novel fiberscope offers a superior intubation experience to currently available best practices. The instrument was well received and would be welcomed by most study participants should the device become clinically available in the future.

Adductor canal block for knee surgical procedures: review article.

Adductor canal block (ACB) has recently emerged as an alternative to femoral nerve block for pain control after various knee procedures especially knee arthroplasty. In this review article, we will review the anatomy of adductor canal, sonoanatomy, and ultrasound-guided approach for ACB as well as review current evidence regarding the indications of the ACB.

Advanced Medical Technology Capacity Building and the Medical Mentoring Event: A Unique Application of SOF Counterinsurgency Medical Engagement Strategies.

Background The Medical Civic Assistance Program (MEDCAP) is a military commander?s tool developed during the Vietnam War to gain access to and positively influence an indigenous population through the provision of direct medical care provided by military medical personnel, particularly in Counter Insurgency Operations (COIN). An alternative to MEDCAPs is the medical seminar (MEDSEM). The MEDSEM uses a Commander?s military medical assets to share culturally appropriate medical information with a defined indigenous population in order to create a sustainable training resource for the local population?s health system. At the heart of the MEDSEM is the ?train the trainer? concept whereby medical information is passed to indigenous trainers who then pass that information to an indigenous population. The MEDSEM achieves the Commander?s objectives of increasing access and influence with the population through a medical training venue rather than direct patient care. Previous MEDSEMS conducted in Afghanistan by military forces focused on improvement of rural healthcare through creation of Village Health Care Workers. This model can also be used to engage host nation (HN) medical personnel and improve medical treatment capabilities in population centers. The authors describe a modification of the MEDSEM, a Medical Mentorship (MM), conducted in November 2010 in Kabul, Afghanistan, at the Afghan National Army (ANA) National Medical Hospital. This training was designed to improve intubation skills in Afghan National Army Hospitals by ANA medical providers, leave residual training capability, and build relationships within the institution that not only assist the institution, but can also be leveraged to foster Commanders? objectives, such as health and reconstruction initiatives and medical partnering for indigenous corps and medical forces described below. Methods We, the authors, developed a culturally appropriate endotracheal intubation training package including a Dari and Pashto instruction manual, Dari video training program, video laryngoscope and difficult airway training mannequin to be used by indigenous medical personnel to train other indigenous medical personnel in the skill of endotracheal intubation. Utilizing Special Operations medical personnel, University of Nebraska medical personnel and local Afghan medical instructors, we coordinated with local authorities and ISAF medical authorities. We trained approximately 100 ANA physician assistant (PA) students and ten ANA intensive care unit (ICU) and Anesthesia medical staff in endotracheal intubation. The video laryngoscope was used as a training aid to guide each student?s direct intubation technique. Results We validated the Medical Mentorship (MM) concept as a means to engage an indigenous population?s medical personnel. The indigenous medical training facilities capability was augmented by use of the video laryngoscope as a training aid. This improvement was sustained over the observable period. Relationships were developed and enhanced for medical support of coalition partner forces supporting SOF operations. Introducing the video laryngoscope to the ICU increased direct care capabilities within the medical institution. Conclusions The MEDSEM is a viable option for military commanders to leverage medical assets to positively engage an indigenous population during COIN operations. MEDSEMs leave residual sustainable medical capabilities, in contrast to MEDCAP models. This report describes a modification of the MEDSEM concept?Medical Mentoring Event (MME)?a short term focused intervention designed to insert medical technology or techniques into an indigenous medical facility that creates sustainable, tangible benefits to patient care while fostering a SOF Commanders objectives. Follow up with embedded NATO trainers at National Military Hospital (NMH) shows that the video laryngoscope continues to be used successfully in airway management training and in difficult intubations, enhanced the teaching impact of imbedded NATO medical mentors, left a residual training capability for Afghan medical instructors and created relationships between SOF medical providers and the host institution that can facilitate healthcare for SOF partner forces.

A comparison of direct versus indirect laryngoscopic visualization during endotracheal intubation of lightly embalmed cadavers utilizing the GlideScope®, Storz Medi Pack Mobile Imaging System™ and the New Storz CMAC™ videolaryngoscope.

BACKGROUND: Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging System™, the Storz CMAC® VL System and the GlideScope®. METHODS: After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected. RESULTS: N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization. CONCLUSION: Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation.