Comparison of Video Laryngoscopy and Direct Laryngoscopy in a Critical Care Transport Service

Prehospital Emergency Care. Posted online on December 11, 2012.

The authors evaluated video laryngoscopy (VL) for use in a critical care transport system and hypothesised that the total number of airway attempts would decrease when using a video laryngoscope versus use of direct laryngoscopy (DL).

A non-randomized group-controlled trial where six aircraft were outfitted with VL and the remainder utilized DL responding to a mix of scene runs and interfacility transports. The primary outcome measure was the number of intubation attempts but the authors also compared the first-pass success (FPS) rates, laryngoscopic grades, and frequencies of rescue device use (including utilization of surgical airways) between VL and DL.

Crews intubated 348 patients with VL and 510 with DL. Successful endotracheal intubation within three attempts occurred 97.6% of the time. The FPS rate was 85.8% . In this cohort of patients, VL did not differ from DL with respect to total number of airway attempts (1.17  vs. 1.16), FPS rate (85.6%  vs. 86.1%), or use of rescue airways (2.6% vs. 2.2%). The laryngoscopic view was superior in the VL group relative to the DL group (median Cormack-Lehane grade 1).

The authors found that VL using the C-MAC video laryngoscope did not reduce the total number of airway attempts or improve intubation compared with DL in a system of highly trained providers but it did improve the lanryngoscopic view.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.729128

Year in review 2011: Critical Care – Out-of-hospital cardiac arrest and trauma 

Critical Care 2012, 16:247

In 2011, numerous studies were published in Critical Care focusing on out-of-hospital cardiac arrest, cardiopulmonary resuscitation, trauma, and some related airway, respiratory, and response time factors. In this review, the authors summarise several of these studies, including those that brought forth advances in therapies for the post-resuscitative period. These advances involved hypothesis-generating concepts in therapeutic hypothermia as well as the impact of early percutaneous coronary artery interventions and the potential utility of extracorporeal life support after cardiac arrest. There were also articles pertaining to the importance of timing in prehospital airway management, the outcome impact of hyperoxia, and the timing of end-tidal carbon dioxide measurements to predict futility in cardiac arrest resuscitation. Subjects covered include:

• Impact of adding percutaneous coronary artery intervention as part of a routine post-resuscitation care bundle following cardiac arrest;
• Oxygenation levels and end-tidal carbon dioxide concentrations during cardiopulmonary resuscitation efforts;
• Extracorporeal life support for out-of-hospital cardiac arrest;
• Additional perspectives on emergency medical service response intervals and outcomes following cardiopulmonary arrest; and
• Evolving insights on prehospital airway management;

The authors added to the growing evidence in support of percutaneous coronary intervention for survivors of OHCA, and time to goal temperature for mild induced therapeutic hypothermiawas found to be a complicated issue. Concerns over hyperoxia in cardiac arrest survivors were again raised, although the impact of this finding may not be as clear as previously thought. The ability of ETCO2 measurement to predict return of pulse was further defined in terms of timelines for making decisions to terminate resuscitative efforts. The articles also provide some evidence for extracoporeal life support as a potential intervention for OHCA. Authors further highlighted the importance of faster responses by prehospital care providers, bystander CPR, and early AED use in the management of OHCA and provided new perspectives such as response time reliability. Finally, it appears that the earliest placement of an advanced airway is important and that extraglottic airways may be a useful alternative to ETI in OHCA. However, in the moderately injured patient, providers may need to be more conservative in their decision to place an endotracheal tube. Nevertheless, depending upon the patient, ETI may still have important utility in trauma care.

© Gary Wilson/ Pre-hospital Research Forum

http://ccforum.com/content/16/6/247  (link to full text article)

Cervical Spine Motion during Extrication

The Journal of Emergency Medicine, 18 October 2012

The authors claim that it has been estimated that up to one-quarter of spinal cord injuries may be significantly worsened during extrication or early treatment after a motor vehicle accident.

© Gary Wilson/ Pre-hospital Research Forum

The purpose of the study was to analyse the planar motions of the head relative to the torso during extrication from an automobile in a laboratory setting.

Video motion capture was used to quantify the range of motion of the head relative to the torso in 10 participants as they were extricated from a mock motor vehicle during four different extrication techniques:

1) Unassisted Unprotected;

2) Unassisted Protected with a cervical collar (CC);

3) Assisted and Protected with a CC;and

4) Assisted and Protected with a CC and Kendrick Extrication Device.

The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

The authors found that in this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics but recommended that further research should be undertaken.

http://www.jem-journal.com/article/S0736-4679(12)01075-X/abstract