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The Difficult Airway Redefined. Prehosp Disaster Med 2022; 37:723-726. [DOI: 10.1017/s1049023x22001455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
There is no all-encompassing or universally accepted definition of the difficult airway, and it has traditionally been approached as a problem chiefly rooted in anesthesiology. However, with airway obstruction reported as the second leading cause of mortality on the battlefield and first-pass success (FPS) rates for out-of-hospital endotracheal intubation (ETI) as low as 46.4%, the need to better understand the difficult airway in the context of the prehospital setting is clear. In this review, we seek to redefine the concept of the “difficult airway” so that future research can target solutions better tailored for prehospital, and more specifically, combat casualty care. Contrasting the most common definitions, which narrow the scope of practice to physicians and a handful of interventions, we propose that the difficult airway is simply one that cannot be quickly obtained. This implies that it is a situation arrived at through a multitude of factors, namely the Patient, Operator, Setting, and Technology (POST), but also more importantly, the interplay between these elements. Using this amended definition and approach to the difficult to manage airway, we outline a target-specific approach to new research questions rooted in this system-based approach to better address the difficult airway in the prehospital and combat casualty care settings.
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Fernandes-Teles AR, Pina-Amado JM, Pereira JM, Paiva JA, Rocha-Silva S. Approaching the airway in prehospital emergency is a common and potentially life-saving practice. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:65-70. [PMID: 35181262 DOI: 10.1016/j.redare.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 01/26/2021] [Indexed: 06/14/2023]
Abstract
Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome.
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Affiliation(s)
- A R Fernandes-Teles
- Department of Anaesthesiology, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal.
| | - J M Pina-Amado
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
| | - J M Pereira
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - J A Paiva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - S Rocha-Silva
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
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Paal P, Zafren K, Pasquier M. Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care. Br J Anaesth 2021; 128:e89-e92. [PMID: 34794765 DOI: 10.1016/j.bja.2021.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 01/30/2023] Open
Abstract
Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
| | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, USA; Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Fernandes-Teles AR, Pina-Amado JM, Pereira JM, Paiva JA, Rocha-Silva S. Approaching the airway in prehospital emergency is a common and potentially life-saving practice. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00109-2. [PMID: 34544597 DOI: 10.1016/j.redar.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 06/13/2023]
Abstract
Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome.
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Affiliation(s)
- A R Fernandes-Teles
- Department of Anaesthesiology, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal.
| | - J M Pina-Amado
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
| | - J M Pereira
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - J A Paiva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - S Rocha-Silva
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
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Steel A, Haldane C, Cody D. Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project. Emerg Med J 2021; 38:549-555. [PMID: 33589515 DOI: 10.1136/emermed-2020-209944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting. METHODS An East of England physician-paramedic PHEM team adopted VL as first line for undertaking all prehospital advanced airway management. The study period was 2016-2020. Statistical process control charts were used to assess whether use of VL altered first-pass intubation success, frequency of intubation-related hypoxia and laryngeal inlet views. A survey was used to collect the team's views of VL introduction. RESULTS 919 patients underwent advanced airway management during the study period. The introduction of VL did not improve first-pass intubation success, view of laryngeal inlet or intubation-associated hypoxia. VL improved situational awareness and opportunities for training but performed poorly in some environments. CONCLUSION Despite the lack of objective improvement in care, subjective improvements meant that overall PHEM clinicians wanted to retain VL within their practice.
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Affiliation(s)
- Alistair Steel
- Magpas Air Ambulance, Huntingdon, Cambridgeshire, UK .,Department of Anaesthesia, Queen Elizabeth Hospital NHS Foundation Trust, King's Lynn, UK
| | - Charlotte Haldane
- Magpas Air Ambulance, Huntingdon, Cambridgeshire, UK.,North West Air Ambulance, Knowsley, UK
| | - Dan Cody
- Magpas Air Ambulance, Huntingdon, Cambridgeshire, UK.,South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
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Luckscheiter A, Lohs T, Fischer M, Zink W. [Airway management in preclinical emergency anesthesia with respect to specialty and education]. Anaesthesist 2020; 69:170-182. [PMID: 32055885 DOI: 10.1007/s00101-020-00737-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/27/2019] [Accepted: 01/14/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Difficult airway management is a key skill in preclinical emergency medicine. A lower rate of subjective difficult airways and an increased success rate of endotracheal intubation have been reported for highly trained emergency physicians. The aim of this study was therefore to analyze the effect for different specialists and the individual state of training in the German emergency medical system. MATERIAL AND METHODS In a retrospective register analysis of 6024 preclinical anesthesia procedures, the frequencies of airway devices, neuromuscular blocking agents, capnography and difficult airways were analyzed with respect to specialization and status of training. Additionally, low, medium and highly experienced emergency physicians in airway management were summarized by specialization and status of training according to the Dreyfus model of skill acquisition and compared. RESULTS The incidence of subjective difficult airway situations was 10% for anesthesiological emergency physicians compared to 15-20% for other disciplines. The latter used supraglottic airway devices more often (7-9% vs. 4%) and video laryngoscopes less often (3% vs. 5%) compared to anesthesiological emergency physicians. The discipline-related state of training was inhomogeneous and revealed a reduced rate of supraglottic airway devices for internal specialists with further training (10% vs. 2%). Anesthetists specialized in intensive care medicine used capnography less frequently compared to other anesthetists (79% vs. 72%). With higher levels of experience in airway management, the frequency of endotracheal intubation (86% vs. 94%), neuromuscular blocking agents (59% vs. 73%) and video laryngoscopy (3% vs. 6%) increased and the incidence of subjective difficult airway situations (16% vs. 10%) decreased. CONCLUSION The level of training in airway management especially for non-anesthetists is inhomogeneous. The recently published German S1 guidelines for prehospital airway management recommend education and training as well as the primary use of the video laryngoscope with Macintosh blade. The implementation could lower the incidence of subjective difficult airways.
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Affiliation(s)
- A Luckscheiter
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen am Rhein, Deutschland.
| | - T Lohs
- Stelle zur trägerübergreifenden Qualitätssicherung im Rettungsdienst Baden-Württemberg (SQR-BW), Stuttgart, Deutschland
| | - M Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Alb Fils Kliniken, Göppingen, Deutschland
- Arbeitsgemeinschaft Südwestdeutscher Notärzte e. V. (AGSWN), Filderstadt, Deutschland
| | - W Zink
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen am Rhein, Deutschland
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Lima DS, de-Vasconcelos IF, Queiroz EF, Cunha TA, Dos-Santos VS, Arruda FAEL, Freitas JG. Multiple victims incident simulation: training professionals and university teaching. Rev Col Bras Cir 2019; 46:e20192163. [PMID: 31389523 DOI: 10.1590/0100-6991e-20192163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/07/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to describe the teaching strategy based on the Multiple Victims Incident (MVI) simulation, discussing and evaluating the performance of the students involved in the initial care of trauma victims. METHODS a cross-sectional, and quantitative study was performed. A realistic MVI simulation involving students, and professionals from nursery and medical schools, as well as a prehospital care team was performed. RESULTS it was possible to notice that the classification according to the START method (Simple Triage and Rapid Treatment) was correct in 94.1% of the time from the analysis of 17 preestablished checklists. Following the primary evaluation with the ABCDE mnemonic, all steps were performed correctly in 70%. However, there was only supply of oxygen in high flow in 64.7% of the examination. The search for visible and hidden bleeding was performed in 70.6% of the examination. The neurological evaluation with the Glasgow coma scale and pupillary evaluation occurred in 70.6% of the victims. The victims exposure was performed in 70.6% of the examination. CONCLUSION a simulated environment allows the consolidation and improvement of professional skills, especially when we are talking about a poorly trained area during the undergraduate program, such as the MVI. Early training and teamwork encourage clinical thinking, integration and communication, essential abilities when facing chaotic situations.
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Affiliation(s)
- Daniel Souza Lima
- Universidade de Fortaleza (UNIFOR), Centro de Ciências da Saúde, Curso de Medicina, Fortaleza, CE, Brasil
| | | | - Erika Feitosa Queiroz
- Universidade de Fortaleza (UNIFOR), Centro de Ciências da Saúde, Curso de Enfermagem, Fortaleza, CE, Brasil
| | - Thaís Aguiar Cunha
- Universidade de Fortaleza (UNIFOR), Centro de Ciências da Saúde, Curso de Enfermagem, Fortaleza, CE, Brasil
| | - Vitória Soares Dos-Santos
- Universidade de Fortaleza (UNIFOR), Centro de Ciências da Saúde, Curso de Enfermagem, Fortaleza, CE, Brasil
| | | | - Julyana Gomes Freitas
- Universidade de Fortaleza (UNIFOR), Centro de Ciências da Saúde, Curso de Enfermagem, Fortaleza, CE, Brasil
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