Comparing the McGrath Mac Video Laryngoscope and Direct Laryngoscopy for Prehospital Emergency Intubation in Air Rescue Patients: A Multicenter, Randomized, Controlled Trial.

OBJECTIVES: Tracheal intubation in prehospital emergency care is challenging. The McGrath Mac Video Laryngoscope (Medtronic, Minneapolis, MN) has been proven to be a reliable alternative for in-hospital airway management. This trial compared the McGrath Mac Video Laryngoscope and direct laryngoscopy for the prehospital setting. DESIGN: Multicenter, prospective, randomized, controlled equivalence trial. SETTING: Oesterreichischer Automobil- und Touring Club (OEAMTC) Helicopter Emergency Medical Service in Austria, 18-month study period. PATIENTS: Five-hundred fourteen adult emergency patients (≥ 18 yr old). INTERVENTIONS: Helicopter Emergency Medical Service physicians followed the institutional algorithm, comprising a maximum of two tracheal intubation attempts with each device, followed by supraglottic, then surgical airway access in case of tracheal intubation failure. No restrictions were given for tracheal intubation indication. MEASUREMENTS MAIN RESULTS: The Primary outcome was the rate of successful tracheal intubation; equivalence range was ± 6.5% of success rates. Secondary outcomes were the number of attempts to successful tracheal intubation, time to glottis passage and first end-tidal CO2 measurement, degree of glottis visualization, and number of problems. The success rate for the two devices was equivalent: direct laryngoscopy 98.5% (254/258), McGrath Mac Video Laryngoscope 98.1% (251/256) (difference, 0.4%; 99% CI, -2.58 to 3.39). There was no statistically significant difference with regard to tracheal intubation times, number of attempts or difficulty. The view to the glottis was significantly better, but the number of technical problems was increased with the McGrath Mac Video Laryngoscope. After a failed first tracheal intubation attempt, immediate switching of the device was significantly more successful than after the second attempt (90.5% vs 57.1%; p = 0.0003), regardless of the method. CONCLUSIONS: Both devices are equivalently well suited for use in prehospital emergency tracheal intubation of adult patients. Switching the device following a failed first tracheal intubation attempt was more successful than a second attempt with the same device.

Success rates of pre-hospital difficult airway management: a quality control study evaluating an in-hospital training program.

BACKGROUND: Competence in emergency airway management is key in order to improve patient safety and outcome. The scope of compulsory training for emergency physicians or paramedics is quite limited, especially in Austria. The purpose of this study was to review the difficult airway management performance of an emergency medical service (EMS) in a region that has implemented a more thorough training program than current regulations require, comprising 3 months of initial training and supervised emergency practice and 3 days/month of on-going in-hospital training as previously reported. METHODS: This is a subgroup analysis of pre-hospital airway interventions performed by non-anesthesiologist EMS physicians between 2006 and 2016. The dataset is part of a retrospective quality control study performed in the ground EMS system of Wiener Neustadt, Austria. Difficult airway missions recorded in the electronic database were matched with the hospital information system and analyzed. RESULTS: Nine hundred thirty-three of 23060 ground EMS patients (4%) required an airway intervention. In 48 cases, transient bag-mask-valve ventilation was sufficient, and 5 patients needed repositioning of a pre-existing tracheostomy cannula. Eight hundred thirty-six of 877 patients (95.3%) were successfully intubated within two attempts; in 3 patients, a supraglottic airway device was employed first line. Management of 41 patients with failed tracheal intubation comprised laryngeal tubes (n = 21), intubating laryngeal mask (n = 11), ongoing bag-mask-valve ventilation (n = 8), and crico-thyrotomy (n = 1). There was no cannot intubate/cannot ventilate situation. Blood gas analysis at admission revealed hypoxemia in 2 and/or hypercapnia in 11 cases. CONCLUSION: During the 11-year study period, difficult airways were encountered in 5% but sufficiently managed in all patients. Thus, the training regime presented might be a feasible and beneficial model for training of non-anesthesiologist emergency physicians as well as paramedics.

In-hospital airway management training for non-anesthesiologist EMS physicians: a descriptive quality control study.

BACKGROUND: Pre-hospital airway management is a major challenge for emergency medical service (EMS) personnel. Despite convincing evidence that the rescuer's qualifications determine efficacy of tracheal intubation, in-hospital airway management training is not mandatory in Austria, and often neglected. Thus we sought to prove that airway management competence of EMS physicians can be established and maintained by a tailored training program. METHODS: In this descriptive quality control study we retrospectively evaluated all in- and pre-hospital airway cases managed by EMS physicians who underwent a structured in-hospital training program in anesthesia at General Hospital Wiener Neustadt. Data was obtained from electronic anesthesia and EMS documentation systems. RESULTS: From 2006 to 2016, 32 EMS physicians with 3-year post-graduate education, but without any prior experience in anesthesia were trained. Airway management proficiency was imparted in three steps: initial training, followed by an ongoing practice schedule in the operating room (OR). Median and interquartile range of number of in-hospital tracheal intubations (TIs) vs. use of supra-glottic airway devices (SGA) were 33.5 (27.5-42.5) vs. 19.0 (15.0-27.0) during initial training; 62.0 (41.8-86.5) vs. 33.5 (18.0-54.5) during the first, and 64.0 (34.5-93.8) vs. 27 (12.5-56.0) during the second year. Pre-hospitaly, every physician performed 9.0 (5.0-14.8) TIs vs. 0.0 (0.0-0.0) SGA cases during the first, and 9.0 (7.0-13.8) TIs vs. 0.0 (0.0-0.3) SGA during the second year. Use of an SGA was mandatory when TI failed after the second attempt, thus accounting for a total of 33 cases. In 8 cases, both TI and SGA failed, but bag mask ventilation was successfully performed. No critical events related to airway management were noted and overall success rate for TI with a max of 2 attempts was 95.3%. DISCUSSION: Number of TIs per EMS physician is low in the pre-hospital setting. A training concept that assures an additional 60+ TIs per year appears to minimize failure rates. Thus, a fixed amount of working days in anesthesia seems crucial to maintain proficiency. CONCLUSIONS: In-hospital training programs are mandatory for non-anesthetist EMS physicians to gain competence in airway management and emergency anesthesia.Our results might be helpful when discussing the need for regulation and financing with the authorities.