Management of hip fractures pre- and post-Major Trauma Centre activation.

INTRODUCTION: In April 2012, the activation of the regional trauma networks in England was carried out to improve the organisation of trauma care. NHS Trusts that could meet the highest standard of care to complex trauma were designated Major Trauma Centres (MTCs). MTCs receive patients fulfilling certain triage criteria, as well as secondary transfers from nearby trauma units. While complex trauma care is streamlined with this new organisation, the impact this would have on the rest of the trauma workload within MTCs as well as non-MTC hospitals is uncertain. We investigate whether the management of hip fracture cases had suffered as a result of a trauma unit becoming a MTC. METHODS: Summary data was collated from the National Hip Fracture Database website for the periods of April 2011-April 2012 (the 'pre-MTC' activation period) and April 2012-April 2013 (the 'post-MTC' activation period). As our primary outcome, we compared the time to surgery within 36h between MTCs and non-MTCs for the periods detailed above. Other outcome measures were: reasons for delay to surgery, length of acute stay, proportion of cases meeting Best Practice Tariff criteria. RESULTS: A total of 54,897 and 55,998 fNOF patients were included for all hospitals in England in the pre- and post-MTC periods respectively. For MTCs, a weighted mean average of 66.6% patients had surgery within 36h in the pre-MTC period versus 71.4% of patients in the post MTC period (p<0.0001). For non-MTCs, a weighted mean average of 70.0% of patients had surgery within 36h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p<0.0001). Non-MTCs in both pre- and post-MTC activation periods were therefore better in percentage of patients receiving surgery within 36h. DISCUSSION: The data presented suggests that the creation of MTCs has not had a deleterious effect on the management of hip fracture patients. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, in conjunction with the development of regional Major Trauma Networks.

Rescue ventilation: resolving a "cannot mask ventilate, cannot intubate" situation during exchange of a Combitube for a definitive airway.

Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.

Comparison of the EasyTube and endotracheal tube during general anesthesia in fasted adult patients.

STUDY OBJECTIVE: To evaluate the effectiveness, safety, ease of placement, and ventilatory parameters of a new alternate airway device, the EasyTube (EzT; Teleflex Ruesch, Research Triangle Park, NC), in comparison to the endotracheal tube (ETT). DESIGN: Prospective, randomized controlled trial. SETTING: University Hospital. SUBJECTS: 200 adult ASA physical status I and II patients scheduled for surgery. INTERVENTIONS: Patients were randomized to two groups, one to receive ventilation via the EzT (n = 100) or the ETT (n = 100). After preoxygenation and induction with fentanyl and propofol, patients received muscle relaxation. The respective airway device was then inserted and mechanical ventilation was instituted. MEASUREMENTS: Ease of insertion, number of insertion maneuvers, time until airtight seal of the airway was achieved, duration of surgery, leak pressure as well as arterial oxygen saturation (SpO(2)), and end-tidal carbon dioxide (ETCO(2)) data, were recorded. MAIN RESULTS: Mallampati airway class was higher in the EzT group (P < 0.029), while thyromental distance showed no difference between the two groups. Ease of insertion was noted in the EzT group (P < 0.043). Number of insertions was equal in both groups; insertion time was shorter with the EzT (15.5 +/- 3.6 sec vs. 19.3 +/- 4.6 sec; P < 0.0001). Leak pressure and SpO(2) were not significantly different, while ETCO(2) was lower with the ETT (P < 0.024). Adjustments had to be made for two EzT group patients. No difference in frequency of laryngo-pharyngeal discomfort was observed in either group. CONCLUSION: Insertion of an EzT appears to reduce time and facilitate placement of an airway device when compared with direct laryngoscopy and tracheal intubation.

Airway management with endotracheal tube versus Combitube during parabolic flights.

BACKGROUND: Training of National Aeronautics and Space Administration space shuttle astronauts revealed difficult airway management with endotracheal tubes (ETTs) under microgravity conditions. The authors performed a randomized comparative study of ETT and Combitube (ETC; Tyco Healthcare, Pleasanton, CA). The aim of the study was to evaluate ease, time of insertion, and success rates during normogravity and parabolic flights using mannequins. METHODS: After normogravity experiments, four flyers performed intubation on a mannequin during the flights. Sixty-two intubation attempts were performed using the ETC (normogravity, 29; microgravity, 33), and 58 intubation attempts were performed using the ETT (each 29 attempts, both conditions). Time to completion of the intubation procedure, success rate, and ease of insertion were recorded. RESULTS: The ETC performed equally well between normogravity (median, 18 s; range, 17-25 s) and microgravity (median, 18.5 s; range, 17-28 s), whereas the ETT performed significantly slower under microgravity (median, 20 s; range, 17-27 s) as compared with normogravity (median, 18 s; range, 16-22 s; P = 0.019). One hundred nine of 120 (90%) were successful. The ETT and ETC were comparable with respect to successful intubations, under normogravity or microgravity, respectively. CONCLUSIONS: Both the ETC and ETT perform comparably well. Slight differences could be found with respect to time of insertion in favor of the ETC. Because this is the first experiment using the ETC on the KC-135, it is shown that there is enough time to perform the insertion procedure. Because the ETC airway requires less training and is easier to insert than an ETT, it is recommended for further study as an alternative airway to what is currently on the shuttle.

The Combitube, self-inflating bulb, and colorimetric carbon dioxide detector to advance airway management in the first echelon of the battlefield.

Combat lifesavers and Army medics are regular combat soldiers who possess skills that enable them to provide lifesaving assistance to combat casualties. Although their training is not equal to that of paramedics, combat lifesavers and Army medics are trained to assess casualties for airway obstruction, as well as the presence or absence of spontaneous ventilation. They are also familiar with the same basic airway maneuvers that are required for blind insertion of the esophageal-tracheal double-lumen airway (ETDLA). Use of the ETDLA in combination with an esophageal detector device and a colorimetric carbon dioxide detector would require skill similar to that which they already possess in performing many mission-essential and combat lifesaver tasks. Because the U.S. Army has introduced the ETDLA for use, it is important that providers at all echelons understand the dynamics of the ETDLA. Inclusion of the ETDLA, esophageal detector device, and colorimetric carbon dioxide detector in combination with the bag-valve ventilation device could provide a viable alternative to mouth-to-mouth rescue breathing with the oral airway, as currently used by combat lifesavers on the battlefield. Improved airway management, in conjunction with other lifesaving measures, could potentially improve survival rates for combat casualties and assist in stabilizing them for evacuation to higher echelons of combat medical care.

Dexmedetomidine as a sole sedating agent with local anesthesia in a high-risk patient for axillofemoral bypass graft: a case report.

The alpha2-agonist dexmedetomidine is indicated for sedation of patients receiving mechanical ventilation in the intensive care unit. It has additional off-label uses for coadministration with local, regional, and general anesthesia. This report describes the use of dexmedetomidine as a sole sedating agent in conjunction with local anesthesia for major vascular surgery. A PubMed literature search produced no previous report of the use of dexmedetomidine as a sole sedating agent used in conjunction with local anesthesia. The anxiolytic, hypnotic-sedative, anesthetic-sparing, and analgesic actions of the drug along with the lack of significant respiratory depressant effects are described. The patient required no airway management with the exception of supplemental mask oxygen. He tolerated the procedure well and was discharged without sequelae on the third postoperative day. Dexmedetomidine should be used judiciously, and understanding the potential adverse effects and how to treat them is of paramount importance. However, with vigilant intraoperative monitoring of blood pressure, heart rate, and level of consciousness, it can be administered safely, thus lessening the anesthetic requirements and possibly improving the surgical outcome of the high-risk patient. This report describes the indications, dosing, off-label uses, pharmacodynamics, pharmacokinetics, and common adverse effects of dexmedetomidine.

The critical airway, rescue ventilation, and the combitube: Part 1.

Emergency and unexpected difficult airway management can rapidly deteriorate into a critical airway event such as "cannot ventilate, cannot intubate" (CVCI). A critical airway event (i.e., inadequate mask ventilation, failed intubation, and CVCI) can be resolved by rescue ventilation, thus avoiding potential neurological disability or death. Recommended options include use of the larygeal mask airway, the esophageal-tracheal Combitube (ETC; Tyco-Healthcare-Nellcor, Pleasanton, Calif), transtracheal jet ventilation, or a surgical airway. This article reviews proper use of the ETC in combination with the self-inflating bulb (SIB) and/or portable carbon dioxide detector to resolve critical airway situations. The combined use of these 3 devices provides on ideal integrated system for airway control and ventilation. In addition, critical airway events and rescue ventilation options; ETC design, technical aspects, training, insertion, and ventilation; determining ETC location (i.e., esophagus vs trachea); and monitoring ETC lung ventilation are reviewed. The SIB primarily assesses ETC location within the esophagus or the trachea; the carbon dioxide detector also permits monitoring lung ventilation. Use of the ETC in prehospital, emergency medicine, and anesthesia settings, including ETC advantages, contraindications, and reported complications will be reviewed in Part 2. How to safely exchange the ETC for a definitive airway also will be reviewed.

The critical airway, rescue ventilation, and the combitube: Part 2.

Emergency and unexpected difficult airway management can rapidly deteriorate into a critical airway event (e.g., inadequate mask ventilation, failed tracheal intubation, or cannot ventilate-cannot intubate). Recommended options to resolve a critical airway event include the laryngeal mask airway, the esophageal tracheal Combitube (ETC; Tyco-Healthcare-Nellcor, Pleasanton, Calif), transtracheal jet ventilation, or a surgical airway to avoid potential neurological disability or death. Part 1, which was published in the February 2004 AANA Journal, reviewed use of the ETC in combination with the self-inflating bulb and/or portable carbon dioxide detector as an effective rescue airway system. Important aspects of rescue ventilation, ETC training methods, how to use the ETC, and determining ETC location also were reviewed. Part 2 reviews ETC advantages, contraindications, and reported complications in prehospital, emergency medicine, and anesthesia settings. Safe methods to exchange the ETC for a definitive airway also are described. Major ETC advantages include the following: (1) easy to learn, (2) can be inserted rapidly, (3) effectively secures the airway, (4) provides adequate lung ventilation, (5) minimizes aspiration risks, (6) facilitates application of high ventilatory pressures, and (7) can be exchanged safely for a definitive airway without compromising airway control or protection.

AANA journal course: update for nurse anesthetists. The SLAM Emergency Airway Flowchart: a new guide for advanced airway practitioners.

Advanced airway practitioners in anesthesiology, emergency medicine, and prehospital care can suddenly and unexpectedly face difficult airway situations that can surface without warning during mask ventilation or tracheal intubation. Although tracheal intubation remains the "gold standard" in airway management, it is not always achievable, and, when it proves impossible, appropriate alternative interventions must be used rapidly to avoid serious morbidity or mortality. The SLAM Emergency Airway Flowchart (SEAF) is intended to prevent the 3 reported primary causes of adverse respiratory events (ie, inadequate ventilation, undetected esophageal intubation, and difficult intubation). The 5 pathways of the SEAF include primary ventilation, rapid-sequence intubation, difficult intubation, rescue ventilation, and cricothyrotomy. It is intended for use with adult patients by advanced airway practitioners competent in direct laryngoscopy, tracheal intubation, administration of airway drugs, rescue ventilation, and cricothyrotomy. The SEAF has limitations (eg, suitable only for use with adult patients, cannot be used by certain categories of rescue personnel, and depends heavily on assessment of Spo2). A unique benefit is provision of simple alternative techniques that can be used when another technique fails.

Use of a gum elastic bougie (GEB) in a zone II penetrating neck trauma: a case report.

A 54-year-old man presented with a deep zone II neck injury accompanied by profuse bleeding secondary to attempting suicide by slashing his anterior neck with a knife. Blind passage of the endotracheal tube (ETT) into the glottis through the open anterior neck was unsuccessful. In a second attempt a gum elastic bougie (GEB) was inserted directly through the vocal cord, and "tracheal clicking" and a "hold up" were appreciated. The ETT was then easily fed over the GEB and was successfully passed into the trachea. The patient underwent operative repair and tracheostomy, and he left the hospital 2 days later with his baseline mental status. The use and the benefits of the GEB are reviewed.