A pilot, prospective trial of IntuBrite® versus Macintosh direct laryngoscopy for paramedic endotracheal intubation in out of hospital cardiac arrest.

BACKGROUND: Intubation in the case of out-of-hospital cardiac arrest (OHCA) is one of the most difficult procedures for Emergency Medical Services (EMS). The use of a laryngoscope with a dual light source is an interesting alternative to classic laryngoscopes. However, there are as yet no prospective data concerning the use of double light direct laryngoscopy (DL) by paramedics in traditional ground ambulance agencies in OHCA. METHODS: We performed a non-blinded trial in a single EMS in Poland within ambulances crews, comparing time and first pass success (FPS) for endotracheal intubation (ETI) in DL using the IntuBrite® (INT) and Macintosh laryngoscope (MCL) during cardiopulmonary resuscitation (CPR). We collected both patient and provider demographic information along with intubation details. The time and success rates were compared using an intention-to-treat analysis. RESULTS: Over a period of 40 months, a total of 86 intubations were performed using 42 INT and 44 MCL based on an intention-to-treat analysis. The FPS time of the ETI attempt (13.49 vs. 15.55 s) using an INT which was shorter than MCL was used (p < 0.05). First attempt success (34/42, 80.9% vs. 29/44, 64.4%) was comparable for INT and MCL with no statistical significance. CONCLUSIONS: We found a statistically significant difference in intubation attempt time when the INT laryngoscope was used. Intubation first attempt success rates with INT and MCL were comparable with no statistical significance during CPR performed by paramedics. TRIAL REGISTRATION: Trial was registered in Clinical Trials: NCT05607836 (10/28/2022).

Comparison of supraglottic airway laryngopharyngeal tube, oropharyngeal and nasopharyngeal airway use by Polish soldiers on the manikin with difficult airway.

UNLABELLED: Airway obstruction represents 6% of avoidable deaths in a combat zone. Statistical analysis of deaths in the battlefield during combat missions in Iraq and Afghanistan shows that 1% of the soldiers are killed because of airway obstruction. The aim of the study was to objectively evaluate the use of S.A.L.T. (Supraglottic Airway Laryngopharyngeal Tube), oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) on the manikin with difficult airway to assess the risk of air introduction into the stomach during ventilation trauma patient and time of insertion of each device. MATERIAL AND METHODS: A prospective study was conducted with the participation of 34 soldiers of the Polish Armed Forces (PAF). They ventilated a manikin using testing devices, to assess the volume of air entering the lungs and the stomach we used specially constructed flowmeters. The mean and median values of all measurements were calculated and compared by means of the Student's t test. RESULTS: 102 device placements and 204 ventilations were performed and evaluated during the study. The median time required for placement of S.A.L.T. was 12.44 sec vs 13.32 sec for NPA vs 9,34 sec for OPA (p<0.05). Mean volumes of air entering the lungs and stomach during ventilation with S.A.L.T. were (ml) 194.23 and 166 respectively, for NPA 218.13 vs 200.93 and for OPA 197.47 vs 169.22. CONCLUSIONS: Total volume of air entering into the stomach using S.A.L.T. was the lowest among all three devices. The use of NPA did not show any clinically important advantage, the fastest insertion time for OPA may be of value in the battlefield.

[Advanced methods of prehospital bleeding management based on the experience and standards of tactical medicine]. / Zaawansowane metody tamowania krwotoku w warunkach przedszpitalnych w oparciu o doswiadczenia i standardy medycyny taktycznej.

Hemostatic agents are currently used in the form of special granules or soaked gauze. Their use is particularly advantageous in difficult body location (e.g. on neck, armpit or groin), where other methods of bleeding control are impossible to use or fail. In a tactical environment tranexamic acid received first class recommendation for use in case of severe bleeding in the US Army. Its application should be considered in case of traumatic amputation, penetrating chest and abdominal trauma or hemorrhagic shock. The aim of the implementation of hypotensive resuscitation is to maintain perfusion of vital organs in patient with hypovolemia, without excessive fluid infusion. Modern method of bleeding control in combat condition are compression clamps. The purpose of these devices is to compress blood vessel by external pressure pads, especially in difficult to access arteries and large veins in the pelvis or in the distal abdominal aorta.

[Modern methods of prehospital bleeding management based on the experience and standards of tactical medicine]. / Wspólczesne metody tamowania krwotoku w warunkach przedszpitalnych w oparciu o doswiadczenia i standardy medycyny taktycznej.

Isolated limb hemorrhage represents 60% of avoidable deaths and remains the leading cause of death in combat zone. Ideal tourniquet must be light, durable and cheap. They should completely stop the flow of arterial blood in the limb, and their attachment should be quick and easy. Tourniquets applied in correct location save lives by stopping the bleeding. Their use in civil environment appear to be particularly relevant in the mass casualties events. Modern bandages used by the military, were designed mostly in the form of an elastic bandage, which attachment has to be easy and quick. Sequential wrapping of elastic dressing around the wound produces compressive force which aim is to stem the bleeding by pressing vessel from the outside. Dressings are made of materials which adhere well to the wound, causing the seal and leave no fragments in the injured tissue. The combination of all components enables fast and effective application of the dressing in the most demanding conditions.

A Comparison of Miller Straight Blade and Macintosh Blade Laryngoscopes for Intubation in Morbidly Obese Patients.

The primary objective of this study was to demonstrate whether the Miller blade laryngoscope could provide better visualization of the vocal cords in morbidly obese patients than the Macintosh blade laryngoscope. The secondary objective was to identify the patient-measured factors associated with better visualization of the vocal cords when using the Miller vs. Macintosh blade, as well as whether the application of external pressure might improve the visibility of the glottis during intubation. A prospective, observational study encompassing 110 patients with a BMI > 40 undergoing elective bariatric surgery and intubation procedure was performed. The evaluation of the vocal cords was performed according to the Cormack-Lehane scale and POGO scale in the same patient during intubation, performed with a Miller and a Macintosh blade laryngoscope, in a random matter. The following parameters were assessed: body weight, height, BMI, neck circumference, thyromental distance, sternomental distance, mouth opening, and Mallampati scale and their impact on visualization of the vocal cords using the Miller blade without the application of external pressure. The Miller blade provides an improved view of the glottis compared to the Macintosh blade measured with both the Cormac-Lehane scale (45 (40.91%) without external pressure application on the larynx, and 18 (16.36%) with external pressure application on the larynx) and the POGO scale (45 (40.91%) without external pressure application on the larynx, and 19 (17.27%) with external pressure application on the larynx). The application of laryngeal pressure improved the view of the glottis. Among the measured features, a significant improvement in the visibility of the glottis could be found in patients with a BMI over 44.244 kg/m2 and a neck circumference over 46 cm. To conclude, the usage of the Miller blade improves the visibility of the glottis compared to the Macintosh blade in morbidly obese patients. The recommendation to use the Miller blade in this group of patients requires further investigation, taking into account the effectiveness of the intubation. Trial Registration: NCT05494463.

A comparison of tracheal intubation using intubrite laryngoscope and conventional MAC laryngoscope: An open, prospective, crossover manikin study.

BACKGROUND: New devices are more available in the pre-hospital environment operational theaters and emergency departments. One is an intubrite laryngoscope (INT) with Dual LED lighting that combines ultraviolet and white LED. The study aimed to compare the efficacy of endotracheal intubation using INT and conventional laryngoscope performed by inexperienced paramedics (paramedics students) and paramedics with experience in advanced airways management in full and limited accessibility settings. METHODS: It was an open, prospective, crossover manikin study. Sixty paramedics and paramedic students were recruited. Participants were divided into 2 equal groups depending on their experience (n = 30). Experienced participants were further randomly divided into 2 groups (n = 15). Inexperienced participants were also randomly divided into 2 groups (n = 15). The criterion of inexperience was 5 or fewer intubation by any laryngoscope. Inexperience participants were asked to perform tracheal intubation in standard pre-hospital settings (without limited access to manikin) (scenario A) and difficult pre-hospital settings (limited access to manikin - narrow space between benches) (scenario B). Experience participants were asked to intubate manikin in difficult pre-hospital settings. RESULTS: In the normal pre-hospital environment, the success rate after the first attempt was 56,7% for conventional laryngoscope and 66,7% for intubrite. However, the overall effectiveness of tracheal intubation using both laryngoscopes in 3 attempts was 90% for both devices. The successful rate of first attempt intubation in a difficult environment by inexperienced was 73,3% for INT and 50% for conventional laryngoscope. Overall effectiveness was 83,3% and 86,7% respectively. The successful rate of first attempt intubation in the experienced group was 86,7% with INT compared to 60% with a conventional laryngoscope in difficult settings. Overall effectiveness was 96,7% for both devices. CONCLUSION: Intubrite provided better working conditions and make up for deficiencies in successful tracheal intubation by inexperienced participants in a normal and difficult environment. Tracheal intubation with intubrite was more effective in the experienced group. Tracheal intubation effectiveness with intubrite was also higher in the experienced group.

Assessment of the Possibility of Using the Laryngoscopes Macintosh, McCoy, Miller, Intubrite, VieScope and I-View for Intubation in Simulated Out-of-Hospital Conditions by People without Clinical Experience: A Randomized Crossover Manikin Study.

The aim of the study was to evaluate the laryngoscopes Macintosh, Miller, McCoy, Intubrite, VieScope and I-View in simulated out-of-hospital conditions when used by people without clinical experience, and to choose the one that, in the case of failure of the first intubation (FI), gives the highest probability of successful second (SI) or third (TI). For FI, the highest success rate (HSR) was observed for I-View and the lowest (LSR) for Macintosh (90% vs. 60%; p < 0.001); for SI, HSR was observed for I-View and LSR for Miller (95% vs. 66,7%; p < 0001); and for TI, HSR was observed for I-View and LSR for Miller, McCoy and VieScope (98.33% vs. 70%; p < 0.001). A significant shortening of intubation time between FI and TI was observed for Macintosh (38.95 (IQR: 30.1-47.025) vs. 32.4 (IQR: 29-39.175), p = 0.0132), McCoy (39.3 (IQR: 31.1-48.15) vs. 28.75 (IQR: 26.475-35.7), p < 0.001), Intubrite (26.4 (IQR: 21.4-32.3) vs. 20.7 (IQR: 18.3-24.45), p < 0.001), and I-View (21 (IQR: 17.375-25.1) vs. 18 (IQR: 15.95-20.5), p < 0.001). According to the respondents, the easiest laryngo- scopes to use were I-View and Intubrite, while the most difficult was Miller. The study shows that I-View and Intubrite are the most useful devices, combining high efficiency with a statistically significant reduction in time between successive attempts.

Is older still good, or even better? Evaluation of possibility of using Miller laryngoscope for intubation in adults and comparison with the most widely used Macintosh laryngoscope. Protocol of a crossover randomized control trial.

Background: Macintosh laryngoscope is the most widely used laryngoscope for intubation. In some patients, e.g. with flaccid, drooping, aplastic epiglottis, usage of this laryngoscope, or even videolaryngoscopes, may not provide visualization of a glottis. Elevation of the laryngopharynx, like in intubation with Miller laryngoscope, may significantly improve intubating conditions. Methods: An anaesthesiologist with over 20 years of experience will perform direct laryngoscopy with randomly chosen Miller or Macintosh blade, evaluating the visibility of rima glottidis with Cormack-Lehane classification and POGO score with and without external laryngeal pressure. Then the second evaluation of glottis with other blade type will be obtained and the patient will be intubated. Comparison of the rima glottidis visibility when using both blades will be the primary endpoint of the study. The secondary endpoints consist of: demonstrating whether there is a group of adult patients in whom the use of the Miller blade associated with better vocal cord visibility may be predicted based on an anesthesiological examination, and whether external laryngeal pressure improves vocal cord visualization more when using the Miller blade compared with the Macintosh blade. Sample size: We performed minimal sample size calculations based on the data derived from the first 60 patients. We assessed the minimal sample size to obtain the alpha of 5 % and power of 90 %. We decide to enroll at least 286 patients. Discussion: this will be the first trial assessing Miller and Macintosh blades in the same population of adult patients. It will determine group of patients in whom Miller laryngoscope will provide better visualization of rima glottidis than Macintosh blade and associated technique, diminishing rate of prolonging intubations and reducing possible aftermaths of hypoxia.

Comparison of Three Video Laryngoscopes and Direct Laryngoscopy for Emergency Endotracheal Intubation While Wearing PPE-AGP: A Randomized, Crossover, Simulation Trial.

BACKGROUND: The COVID-19 pandemic has necessitated changes in the safety protocols of endotracheal intubation at every level of care. This study aimed to compare the first-pass success rates (FPS) and intubation times (IT) of three video laryngoscopes (VL) and direct laryngoscopy (DL) for simulated COVID-19 patient emergency intubation (EI). METHODS: The study was a prospective, randomized, crossover trial. Fifty-three active paramedics performed endotracheal intubation with the I-viewTM VL, UESCOPE® VL, ProVu® VL and Macintosh direct laryngoscope (MAC) wearing personal protective equipment for aerosol-generating procedures (PPE-AGP) on a manikin with normal airway conditions. RESULTS: The longest IT was noted when the UESCOPE® (29.4 s) and ProVu® (27.7 s) VL were used. The median IT for I-view was 17.4 s and for MAC DL 17.9 s. The FPS rates were 88.6%, 81.1%, 83.0% and 84.9%, respectively, for I-view, ProVu®, UESCOPE® and MAC DL. The difficulty of EI attempts showed a statistically significant difference between UESCOPE® and ProVu®. CONCLUSIONS: The intubation times performed by paramedics in PPE-AGP using UESCOPE® and ProVu® were significantly longer than those with the I-view and Macintosh laryngoscopes. The use of VL by prehospital providers in PPE did not result in more effective EI than the use of a Macintosh laryngoscope.