103 Does Video-Assisted Laryngoscopy Improve Outcomes in Cardiac Arrest Patients Who Are Intubated Out-of-Hospital?

103 Does Video-Assisted Laryngoscopy Improve Outcomes in Cardiac Arrest Patients Who Are Intubated Out-of-Hospital?

Research Forum Abstracts 101 Comparison of the FlexView Video Laryngoscope, Macintosh Blade Direct Laryngoscope, and the GlideScope Video Laryngosco...

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Research Forum Abstracts

101

Comparison of the FlexView Video Laryngoscope, Macintosh Blade Direct Laryngoscope, and the GlideScope Video Laryngoscope

Adams J, Haston T, Reynolds BZ/Georgia Regents University, Augusta, GA

Study Objectives: Video laryngoscopy was developed with the hope of increasing the success rate of endotracheal intubation over that of direct laryngoscopy. Previous study results evaluating this have been mixed. The aim of this study was to evaluate direct laryngoscopy (DL), the GlideScope video laryngoscope (GVL) and a new articulating video laryngoscope, the FlexView (FV), on a routine and a difficult airway simulator. Outcome variables included: failure rate, time (in seconds) to intubation (TF), glottic view (as reflected by a modified Cormack-Lehane score), and perceived difficulty (using a 5-point Likert scale). Methods: Thirty-seven emergency medicine residents at differing levels of training participated in this study. Participants were provided demonstration of equipment use and up to three practice attempts with each device on a standard airway simulator. Participants were then observed intubating with each device, in a randomized order, on routine and difficult airway simulators. A Tru Corp Airsim Standard was utilized to simulate the routine airway. A Tru Corp Airsim Advance was utilized to simulate the difficult airway by the use of a cervical collar with occiput elevation and neck flexion along with a swollen tongue. After using the devices on the routine airway simulator, participants used each device on the difficult airway simulator. Intubation times surpassing 120 seconds were considered “failures” but capped as such for the time variable. After using each device, participants rated the glottic view and level of difficulty. Glottic view was scored using the Modified Cormack-Lehane Score. Level of difficulty was based on a 5-point Likert scale item, ranging from 1 (very easy) to 5 (very hard). Results: All routine airway intubations were successful, but there was one (2.7%) failure using the DL and four (10.8%) failures using the GVL on the difficult airway. Friedman’s test was used for the following analyses; all post-hoc analyses used a Bonferroni correction. For the routine airway, the DL (Mdn¼11.55; P < .001) and FV (Mdn¼12.50; P ¼ .044) were significantly faster than the GVL (Mdn¼15.06). The GVL (Mdn¼1; P ¼ .001) and FV (Mdn¼1; p¼.002) had better self-reported glottic views than the DL (Mdn¼2). There were no statistical differences among devices for ease of use. For the difficult airway, the FV (Mdn¼27.76) was significantly faster than the GVL (Mdn¼42.28; P ¼ .032) while the DL (Mdn¼35.43) was not significantly different from either. The GVL (Mdn¼2; P ¼ .004) and FV (Mdn¼1; P < .001) had better selfreported glottic views than the DL (Mdn ¼ 2). Lastly, the FV (Mdn¼2) was rated significantly easier than the DL (Mdn¼4; P < .001) and GVL (Mdn¼4; P ¼ .001). Conclusion: With a routine airway, the DL and FV yielded quicker intubation times while video laryngoscopy (GVL and FV) yielded better views. Devices did not differ significantly with regards to perceived ease of use. With a difficult airway, the FV was superior in terms of successful intubation, time to intubation, glottic view, and ease of use. These results suggest that the new articulating video laryngoscope, FlexView, is superior to DL and GVL when performing intubation of restricted airways.

102

STABCric 2: Surgical Technique Against Bougie Cricothyrotomy

Layng E, Berrios M, Kadish J, Pester JM/St Luke’s University Hospital, Bethlehem, PA

Study Objective: Performing a surgical airway is a last resort heroic measure when a physician cannot ventilate nor intubate a patient. The traditionally taught open surgical technique is prone to error by using multiple tools in multiple steps. By adapting other novel bougie assisted methods we have developed a video instrument demonstrating a simplified 3-step method using only a scalpel and bougie. This observational study examines if the bougie-assisted cricothyrotomy is more rapidly performed than the classically taught open surgical method. Methods: This was an observational crossover study using pig tracheas oversewn with pig skin. Participants included emergency medicine residents as well as emergency medicine advanced practitioners at St. Luke’s University Hospital. Participants were randomized to one of the two techniques then shown an instructional video prior to the procedure. After a four-week washout period, the same participants were brought back to perform the other cricothyrotomy technique. The primary outcome measure was time to correct endotracheal tube placement. Secondary outcomes included time spent learning each technique, and number of attempts at tube placement. Results: Thirteen residents and a PA fellow were included in the study. Median time to placement for the bougie-assisted technique was 61 seconds (interquartile range

S36 Annals of Emergency Medicine

[IQR] ¼ 52-100 seconds) versus 125 seconds (IQR ¼ 119-219 seconds) for the surgical technique (P ¼ .023). Median time to learn was also significantly faster for the bougie technique at 159 seconds (IQR ¼ 155-164 seconds) versus 230 seconds (IQR ¼ 206-351 seconds) for the surgical technique (P ¼ .001). The median number of attempts was 1 (IQR ¼ 1.0-1.5 attempts) for the bougie-assisted method versus 1 (IQR ¼ 1.0-2.0 attempts) for the surgical method (P ¼ .366). Conclusion: This study demonstrates that the bougie-assisted method is both quicker to perform as well as more rapidly learned when compared to the traditionally taught open surgical cricothyrotomy technique. The number of attempts to achieve proper placement was not significant for either technique. In patients requiring emergent cricothyrotomy, we recommend the bougie-assisted method as a first-line surgical airway method.

103

Does Video-Assisted Laryngoscopy Improve Outcomes in Cardiac Arrest Patients Who Are Intubated Out-of-Hospital?

Walsh B, Clayton L, Feldman D/Morristown Memorial Hospital, Morristown, NJ; Morristown Medical Center, Morristown, NJ

Study Objectives: Out-of-hospital intubation of cardiac arrest patients is controversial with some studies suggesting that the intubation process limits effective compressions. However, advances in video-assisted laryngoscopy (VAL) have improved the efficiency of intubation. It is unclear if the use of VAL improves outcomes in cardiac arrest patients who are intubated out-of-hospital. We sought to determine if there is improved survival to hospital admission in cardiac arrest patients who are intubated out-of-hospital using VAL versus those in whom traditional direct laryngoscopy (DL) is used. Methods: Design: Retrospective Cohort. Setting: A large suburban, two-tiered advanced life support (ALS) system that evaluates approximately 27,000 patients per year. Subjects: Consecutive patients in cardiac arrest who were intubated out-ofhospital by ALS providers over an 18-month period. Patients were divided into groups based on whether VAL or direct laryngoscopy was used as the method for intubation. ALS providers are encouraged to use VAL as the primary method of intubation, but can use DL at their discretion. We reviewed patient records to determine the intubation method used, whether the intubation was successful on the first attempt, and whether the patient survived to hospital admission. We compared the differences between the rates of survival to admission between the two groups and calculated 95% confidence intervals (CI). Results: Out of 480 total intubations, there were 354 in the VAL group and 126 in the DL group. 64% of the VAL group and 73% of the DL group were in cardiac arrest. There were no differences in age or sex between the two groups. First attempt success rate was 76% (72, 80) in the VAL group and 84% (76, 91) in the DL group (difference 8%, CI -3, 16). Survival to hospital admission was 33% (CI: 27, 39) in the VAL group and 15% (CI: 8, 23) in the DL group. The difference in survival to hospital admission was 17% (CI: 7, 26; P < .05). Conclusion: Compared to DL, VAL appears to improve survival to hospital admission in cardiac arrest patients who are intubated out-of-hospital.

104

Complications Related to Multiple Endotracheal Intubation Attempts in the Emergency Department

Zhang MG, Minhas K, Duggan LV, Royal Columbian Airway Committee/University of British Columbia, Vancouver, BC, Canada

Study Objectives: The objective of this study was to determine the association between one endotracheal intubation (ETI) attempt versus greater than one ETI attempt with complication rates in the emergency department (ED). Methods: This is a prospective observational study involving consecutive adult ETI procedures performed in the ED over a 28-month period. The study took place at Royal Columbian Hospital, a 402-bed, tertiary care teaching hospital in Canada between July 2012 and November 2014. Respiratory therapists (RTs) attend every out of operating room ETI procedure. As part of an ongoing quality improvement initiative, RTs prospectively collect data regarding indication, number of attempts, urgency, primary operator level of experience, technique and complications. The primary outcome measure was the complication rate associated with one versus greater than one ETI attempt. An attempt was defined as the placement and removal of an intubation device into the oral cavity. Severe complications were defined as

Volume 66, no. 4s : October 2015