The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation.

BACKGROUND: Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI. METHODS: This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct. RESULTS: Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm). CONCLUSIONS: Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.

Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success.

BACKGROUND: Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. METHODS: This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. RESULTS: Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). CONCLUSIONS: In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.

Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management.

Multiple international airway societies have created guidelines for the management of the difficult airway. In critically ill patients, there are physiologic derangements beyond inadequate airway protection or hypoxemia. These risk factors contribute to the "physiologically difficult airway" and are associated with complications including cardiac arrest and death. Importantly, they are largely absent from international guidelines. Thus, we created management recommendations for the physiologically difficult airway to provide practical guidance for intubation in the critically ill. Through multiple rounds of in-person and telephone conferences, a multidisciplinary working group of 12 airway specialists (Society for Airway Management's Special Projects Committee) over a time period of 3 years (2016-2019) reviewed airway physiology topics in a modified Delphi fashion. Consensus agreement with the following recommendations among working group members was generally high with 80% of statements showing agreement within a 10% range on a sliding scale from 0% to 100%. We limited the scope of this analysis to reflect the resources and systems of care available to out-of-operating room adult airway providers. These recommendations reflect the practical application of physiologic principles to airway management available during the analysis time period.

Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go.

Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: 1) preintubation assessment for potential difficulty (e.g., MACOCHA score); 2) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and 3) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.

Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period.

OBJECTIVE: There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED. METHODS: This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age. RESULTS: During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]). CONCLUSIONS: In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.

Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department.

STUDY OBJECTIVE: Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department. METHODS: This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%. RESULTS: We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction. CONCLUSION: ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.

Analgosedative interventions after rapid sequence intubation with rocuronium in the emergency department.

OBJECTIVES: The use of etomidate and rocuronium for rapid sequence intubation (RSI) results in a duration of paralysis that exceeds the duration of sedation. The primary objective of this study was to compare the number of analgosedative (AGS) interventions early versus late post-RSI, with this drug combination. The secondary objective was to descriptively assess time to first AGS intervention. METHODS: This was a retrospective cohort study conducted in an academic ED in the United States between January 2015 and June 2016. The study was conducted after a pharmacy-led education program. Consecutive adult patients who received the combination of etomidate and rocuronium for RSI were included. The primary outcome measure was the number of AGS interventions post-RSI. An AGS intervention was defined as initiation of an opioid or sedative, or a dose increase of an infusion rate. Interventions were categorized as early (0-30min post-RSI) or late (60-90min post-RSI). RESULTS: The sample (n=108) had a mean age of 58±19years, and the majority was male (n=62, 57%). The mean rocuronium dose was 1.1±0.3mg/kg. There was a median of 2 interventions (IQR 1-3) that occurred early versus 0 interventions (IQR 0 to 1) that occurred late post-RSI (p<0.001). The median time to first AGS intervention was 7min (IQR 3 to 13min). CONCLUSIONS: When rocuronium was used for RSI in the ED there was no delay in provision of post-intubation sedation or analgesia, after a pharmacy-led educational program.

Management of Patients with Predicted Difficult Airways in an Academic Emergency Department.

BACKGROUND: Patients with difficult airways are sometimes encountered in the emergency department (ED), however, there is a little data available regarding their management. OBJECTIVES: To determine the incidence, management, and outcomes of patients with predicted difficult airways in the ED. METHODS: Over the 1-year period from July 1, 2015 to June 30, 2016, data were prospectively collected on all patients intubated in an academic ED. After each intubation, the operator completed an airway management data form. Operators performed a pre-intubation difficult airway assessment and classified patients into routine, challenging, or difficult airways. All non-arrest patients were included in the study. RESULTS: There were 456 patients that met inclusion criteria. Fifty (11%) had predicted difficult airways. In these 50 patients, neuromuscular blocking agents (NMBAs) were used in 40 (80%), an awake intubation technique with light sedation was used in 7 (14%), and no medications were used in 3 (6%). In the 40 difficult airway patients who underwent NMBA facilitated intubation, a video laryngoscope (GlideScope 21, Verathon, Bothell, WA and C-MAC 19, Karl Storz, Tuttlingen, Germany) was used in each of these, with a first-pass success of 90%. In the 7 patients who underwent awake intubation, a video laryngoscope was used in 5, and a flexible fiberoptic scope was used in 2. Ketamine was used in 6 of the awake intubations. None of these difficult airway patients required rescue with a surgical airway. CONCLUSIONS: Difficult airways were predicted in 11% of non-arrest patients requiring intubation in the ED, the majority of which were managed using an NMBA and a video laryngoscope with a high first-pass success.

Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department.

OBJECTIVES: The primary objective of this study was to determine the association between patient weight and first pass success (FPS) during rapid sequence intubation (RSI) in the ED. The secondary objective was to evaluate the association between patient weight and neuromuscular blocking agent (NMBA) dosing. METHODS: This was a retrospective cohort study conducted in a tertiary care academic ED. Consecutive adult patients who underwent RSI in the ED between January 2014 and June 2016 were included. Data were collected on patient, operator and procedural characteristics. The cohort was categorised into the following weight strata: <80 kg, 80 to <100 kg, 100 to <120 kg and ≥120 kg. The primary outcome of interest was FPS. A multivariable logistic regression analysis was conducted to evaluate the relationship between patient weight category and FPS. NMBA dosing was reported descriptively. RESULTS: The sample included 891 patients. FPS for each weight category was as follows: <80 kg (91%), 80 to <100 kg (90%), 100 to <120 kg (91%) and ≥120 kg (76%). After adjusting for potential confounders, the heaviest weight category was associated with decreased odds of FPS (OR 0.2, 95% CI 0.1 to 0.5, p<0.001). Median doses for succinylcholine (based on total body weight) decreased as weight increased: <80 kg (1.5 mg/kg), 80 to <100 kg (1.3 mg/kg), 100 to <120 kg (1.2 mg/kg) and ≥120 kg (1.0 mg/kg). Median doses for rocuronium (based on ideal body weight) were similar across weight categories: <80 kg (1.3 mg/kg), 80 to <100 kg (1.4 mg/kg), 100 to <120 kg (1.3 mg/kg) and ≥120 kg (1.4 mg/kg). CONCLUSIONS: Very heavy patients (>120 kg) undergoing RSI in the ED had a reduced FPS, and succinylcholine was more commonly underdosed than rocuronium in the heavier weight group.

The Utility of the C-MAC as a Direct Laryngoscope for Intubation in the Emergency Department.

BACKGROUND: Although the C-MAC (Karl Storz, Tuttlingen, Germany) is a video laryngoscope (VL), it can also be used as a direct laryngoscope (DL). OBJECTIVE: The goal of this study was to evaluate the utility of the C-MAC as a DL for intubations in the emergency department (ED). METHODS: This was an analysis of prospectively collected continuous quality-improvement data during the 6-year period from February 1, 2009 to January 31, 2015, when both the C-MAC and Macintosh DL (Mac DL) were clinically available in our ED. This analysis included adult patients who underwent rapid sequence intubation by an emergency medicine resident in the ED with a C-MAC initially used as a DL or a Mac DL. The primary outcome measure was the first pass success (FPS). RESULTS: When the C-MAC was used as a DL, the initial DL attempt was successful in 199 of 346 (57.6%) cases. When the attempt could not be completed using the C-MAC as a DL, the operator utilized the video monitor and successfully completed the intubation using VL in 104 of 134 (77.6%) cases, thus achieving an overall FPS of 303 of 346 (87.6%). When the Mac DL was used, the FPS was 505 of 671 (75.3%). CONCLUSIONS: The C-MAC is a useful device for DL because in the event of a failed DL attempt, operators have the option of switching to the video monitor to successfully complete the intubation using VL without having to make a second attempt.

A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients.

BACKGROUND: Direct laryngoscopy (DL) has long been the gold standard for tracheal intubation in emergency and trauma patients. Video laryngoscopy (VL) is increasingly used in many settings and the purpose of this study was to compare its effectiveness to direct laryngoscopy in trauma patients. Our hypothesis was that the success rate of VL would be higher than that of DL. METHODS: Data were collected prospectively on all trauma patients, from January 2008 to June 2011, who were intubated emergently in an academic level I trauma center. After intubation, the physician that performed the intubation completed a structured data collection form that included demographics, complications, and the presence of difficult airway predictors. Our primary outcome measure was overall successful tracheal intubation, which was defined as successful intubation with the first device used. RESULTS: During the study period, 709 trauma patients were intubated by either VL or DL. VL was performed in 55% of cases. The overall success rate of VL was 88% compared to 83% with DL (P = 0.05). Cervical (C-Spine) immobilization was predictive of higher initial success with VL (87%) than with DL (80%) (P < 0.05). In multivariate regression analysis DL was associated with higher risk of intubation failure compared to VL (OR 1.82, CI: 1.15-2.86). CONCLUSIONS: In trauma patients intubated emergently, VL had a significantly higher success rate than DL. These data suggest that, in select circumstances, VL is superior to DL for the intubation of trauma patients with difficult airways.

The C-MAC® video laryngoscope is superior to the direct laryngoscope for the rescue of failed first-attempt intubations in the emergency department.

OBJECTIVE: To compare the effectiveness of the C-MAC® video laryngoscope (CMAC) to the direct laryngoscope (DL) when used to rescue a failed first attempt intubation in the emergency department (ED). METHODS: Data were prospectively collected on all patients intubated in an academic ED center over a five-year period from February 1, 2009 to January 31, 2014 when both the CMAC and the DL were available. Following each intubation the operator completed a continuous quality improvement (CQI) form documenting patient, operator and intubation characteristics. All orotracheal intubations attempted by emergency physicians (EPs) on adult patients with a failed first intubation attempt, and in which the CMAC or the DL was used for the second attempt, were included. The primary outcome was successful intubation on the second attempt using either the CMAC or the DL. A multivariate logistic regression analysis was performed to adjust for potential confounders. RESULTS: During the five-year study period, there were 460 adult orotracheal intubation attempts by EPs which were not successful on the first attempt. In 398 (86.5%) of these cases the same operator performed the second attempt. The CMAC was utilized for the second attempt in 141 cases and was successful in 116 (82.3%; 95% CI 75.0%-88.2%) and the DL was utilized in 94 cases and was successful in 58 (61.7%; 95% CI 51.1%-71.5%). In a multivariate logistic regression analysis the CMAC was associated with an increased odds (adjusted OR 3.5; 95% CI 1.9-6.7) of a second attempt success compared to the DL. CONCLUSIONS: After a failed first intubation attempt in the ED, regardless of the initial device used, the CMAC was more successful than the DL when used for the second attempt. This suggests that the CMAC is the preferred rescue device after an initial intubation attempt in the ED fails.

Telepresent intubation supervision is as effective as in-person supervision of procedurally naive operators.

BACKGROUND: Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. MATERIALS AND METHODS: A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. RESULTS: There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. CONCLUSIONS: In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.

Association Between Difficult Airway Predictors and Failed Prehosptial Endotracheal Intubation.

OBJECTIVE: Difficult airway predictors (DAPs) are associated with failure of endotracheal intubation (ETI) in the emergency department (ED). The purpose of this study was to determine if DAPs are associated with failure of prehospital ETI. METHODS: This retrospective study compared the prevalence of DAPs in cases of failed prehospital ETI successfully intubated in the ED (FPH/SED) with cases with no prehospital attempt that were successfully intubated in the ED on the first attempt by a physician using direct laryngoscopy (NPH/SED). All cases were transported by ground or air to an academic, level-1 trauma center. RESULTS: A total of 1377 ED ETIs were performed; 161 FPH/SED and 530 NPH/SED were identified. The odds ratios with 95% confidence intervals (CIs) of finding DAPs in the FPH/SED group compared with the NPH/SED group was blood = 5.80 (95% CI, 3.89-8.63), vomit = 2.01 (95% CI, 1.25-3.21), short neck = 2.67 (95% CI, 1.39-5.03), neck immobility = 2.52 (95% CI, 1.72-3.67), airway edema = 10.52 (95% CI, 4.15-29.92), facial trauma = 4.64 (95% CI, 2.91-7.39), and large tongue = 3.08 (95% CI, 1.75-5.40). When grouped by the number of DAPs per case (0, 1, 2, 3, or ≥ 4), the odds of multiple DAPs in cases of FPH/SED compared with NPH/SED ranged from 2.89 (95% CI, 1.71-4.90) with 1 DAP to 24.55 (95% CI, 10.60-56.90) with ≥ 4 DAPs. CONCLUSION: Cases of FPH/SED have more DAPs than NPH/SEDs.

A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department.

STUDY OBJECTIVE: There is growing use of video laryngoscopy in US emergency departments (EDs). This study seeks to compare intubation success between the GlideScope video laryngoscope and the C-MAC video laryngoscope (C-MAC) in ED intubations. METHODS: This was an analysis of quality improvement data collected during a 3-year period in an academic ED. After each intubation, the operator completed a standardized data form reporting patient demographics, indication for intubation, device(s) used, reason for device selection, difficult airway characteristics, number of attempts, and outcome of each attempt. An attempt was defined as insertion of the device into the mouth regardless of attempt at tube placement. The primary outcomes were first pass and overall intubation success. The study compared success rates between the GlideScope video laryngoscope and the C-MAC groups, using multivariable logistic regression and adjusting for potential confounders. RESULTS: During the 3-year study period, there were 463 intubations, including 230 with the GlideScope video laryngoscope as the initial device and 233 with the C-MAC as the initial device. The GlideScope video laryngoscope resulted in first-pass success in 189 of 230 intubations (82.2%; 95% confidence interval [CI] 76.6% to 86.9%) and overall success in 221 of 230 intubations (96.1%; 95% CI 92.7% to 98.2%). The C-MAC resulted in first-pass success in 196 of 233 intubations (84.1%; 95% CI 78.8% to 88.6%) and overall success in 225 of 233 intubations (96.6%; 95% CI 93.4% to 98.5%). In a multivariate logistic regression analysis, the type of video laryngoscopic device was not associated with first-pass (odds ratio 1.1; 95% CI 0.6 to 2.1) or overall success (odds ratio 1.2; 95% CI 0.5 to 3.1). CONCLUSION: In this study of video laryngoscopy in the ED, the GlideScope video laryngoscope and the C-MAC were associated with similar rates of intubation success.

Video laryngoscopy improves intubation success and reduces esophageal intubations compared to direct laryngoscopy in the medical intensive care unit.

INTRODUCTION: Tracheal intubation in the Intensive Care Unit (ICU) can be challenging as patients often have anatomic and physiologic characteristics that make intubation particularly difficult. Video laryngoscopy (VL) has been shown to improve first attempt success compared to direct laryngoscopy (DL) in many clinical settings and may be an option for ICU intubations. METHODS: All intubations performed in this academic medical ICU during a 13-month period were entered into a prospectively collected quality control database. After each intubation, the operator completed a standardized form evaluating multiple aspects of the intubation including: patient demographics, difficult airway characteristics (DACs), method and device(s) used, medications used, outcomes and complications of each attempt. Primary outcome was first attempt success. Secondary outcomes were grade of laryngoscopic view, ultimate success, esophageal intubations, and desaturation. Multivariate logistic regression was performed for first attempt and ultimate success. RESULTS: Over the 13-month study period (January 2012-February 2013), a total of 234 patients were intubated using VL and 56 patients were intubated with DL. First attempt success for VL was 184/234 (78.6%; 95% CI 72.8 to 83.7) while DL was 34/56 patients (60.7%; 95% CI 46.8 to 73.5). Ultimate success for VL was 230/234 (98.3%; 95% CI 95.1 to 99.3) while DL was 52/56 patients (91.2%; 95% CI 81.3 to 97.2). In the multivariate regression model, VL was predictive of first attempt success with an odds ratio of 7.67 (95% CI 3.18 to 18.45). VL was predictive of ultimate success with an odds ratio of 15.77 (95% CI 1.92 to 129). Cormack-Lehane I or II view occurred 199/234 times (85.8%; 95% CI 79.5 to 89.1) and a median POGO (Percentage of Glottic Opening) of 82% (IQR 60 to 100) with VL, while Cormack-Lehane I or II view occurred 34/56 times (61.8%; 95% CI 45.7 to 71.9) and a median POGO of 45% (IQR 0 to 78%) with DL. VL reduced the esophageal intubation rate from 12.5% with DL to 1.3% (P = 0.001) but there was no difference in desaturation rates. CONCLUSIONS: In the medical ICU, video laryngoscopy resulted in higher first attempt and ultimate intubation success rates and improved grade of laryngoscopic view while reducing the esophageal intubation rate compared to direct laryngoscopy.

Effect of paralytic type on time to post-intubation sedative use in the emergency department.

OBJECTIVE: To determine the difference between rocuronium and succinylcholine with regard to post-intubation sedative initiation in the emergency department. METHDS: This was a retrospective cohort study conducted in a tertiary care emergency department (ED) in the USA. Consecutive adult patients intubated in the ED using succinylcholine or rocuronium for paralysis were included. Data collected included patient demographics, vital signs, medications used post-intubation and times of drug administration. Patients were divided into two groups based on the type of paralytic used for rapid sequence intubation: (1) rocuronium or (2) succinylcholine. All patients received etomidate for induction of sedation. Time between intubation and post-intubation sedative use was compared between the two groups using an unpaired Student's t test. MAIN RESULTS: A total of 200 patients were included in the final analyses (100 patients in each group). There were no significant differences between the groups with regard to patient demographics, vital signs or other baseline characteristics. After intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7). The remaining patients received sedation as bolus doses only. Mean time between intubation and post-intubation sedative use was significantly greater in the rocuronium group compared with the succinylcholine group (27 min vs 15 min, respectively; p<0.001). CONCLUSIONS: Patients intubated with rocuronium had greater delays in post-intubation sedative initiation compared with succinylcholine.

Telebation: next-generation telemedicine in remote airway management using current wireless technologies.

INTRODUCTION: Since the first remote intubation with telemedicine guidance, wireless technology has advanced to enable more portable methods of telemedicine involvement in remote airway management. MATERIALS AND METHODS: Three voice over Internet protocol (VoIP) services were evaluated for quality of image transmitted, data lag, and audio quality with remotely observed and assisted intubations in an academic emergency department. The VoIP clients evaluated were Apple (Cupertino, CA) FaceTime(®), Skype™ (a division of Microsoft, Luxembourg City, Luxembourg), and Tango(®) (TangoMe, Palo Alto, CA). Each client was tested over a Wi-Fi network as well as cellular third generation (3G) (Skype and Tango). RESULTS: All three VoIP clients provided acceptable image and audio quality. There is a significant data lag in image transmission and quality when VoIP clients are used over cellular broadband (3G) compared with Wi-Fi. CONCLUSIONS: Portable remote telemedicine guidance is possible with newer technology devices such as a smartphone or tablet, as well as VoIP clients used over Wi-Fi or cellular broadband.