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Blind intubation through the supraglottic airway laryngopharyngeal tube with a biohazard suit
2040
Correspondence / American Journal of Emergency Medicine 34 (2016) 2029–2049
After finishing, the patient's fingers should be freed from the fingertraps and ice should be applied external to the splint.
Kalpit N. Shah * Andrew D. Sobel Edward Akelman Andrea Halim Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University * Corresponding author at: 593 Eddy St., Providence, RI, 02903. Tel.: +1 858 436 6070. E-mail address: [email protected] (K.N. Shah).
http://dx.doi.org/10.1016/j.ajem.2016.07.038 References [1] Ilyas AM, Jupiter JB. Distal radius fractures—classification of treatment and indications for surgery. Hand Clin 2010;26:37–42. [2] Koval K, Haidukewych GJ, Service, B, Zirgibel BJ. Controversies in the Management of Distal Radius Fractures. J Am Acad Orthop Surg 2014;22:566–75. [3] Earnshaw SA, Aladin A, Surendran S, Moran CG. Closed reduction of Colles fractures: comparison of manual manipulation and finger-trap traction. J Bone Joint Surg Am 2002;84:354–8. [4] Charnley J. The closed treatment of common fractures. Cambridge University Press; 2003[at https://books.google.com/books?id=HTiqWb530MYC]. [5] Grafstein E, Stenstrom R, Christenson J, Innes G, MacCormack R, Jackson C, et al. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures. Can J Emerg Med 2010;12:192–200. [6] Dée W, Klein W, Rieger H. Reduction techniques in distal radius fractures. Injury 2000;31:48–55 [Supple]. [7] Eichinger JK, Agochukwu U, Franklin J, Arrington ED, Bluman EM. A new reduction technique for completely displaced forearm and wrist fractures in children. J Pediatr Orthop 2011;31:e73–9.
Blind intubation through the supraglottic airway laryngopharyngeal tube with a biohazard suit To the Editor, Securing the airway belongs to the basic skills of medical personnel, including paramedics. Currently, tracheal intubation is considered the gold standard for airway management [1]. If properly performed, it isolates the respiratory tract, eliminating or significantly reducing the risk of gastric contents aspiration into the airway [2]. However, from the disaster medicine point of view, in numerous situations, because of the risk to their life and health, paramedics should perform rescue management activities using protective clothing of highest priority, i.e. the chemical, biological, radiological and nuclear personal protective equipment (CBRN-PPE) [3-5]. The use of CBRN-PPE during endotracheal intubation with direct laryngoscopy can exert a negative impact on the efficacy of intubation. A solution may be blind intubation via supraglottic airway devices [6]. The aim of the study was to evaluate the effectiveness of blind intubation through the supraglottic airway laryngopharyngeal tube (SALT) performed by paramedics with and without CBRN-PPE. This prospective, randomized crossover manikin study was reviewed and approved by the Institutional Review Board of the Polish Society of Disaster Medicine (approval No. 06.05.2016.17) and was conducted in July 2016. Twenty-five paramedics who had performed more than 30 direct laryngoscopic intubations and had more than one-year experience in the Emergency Medical Service were enrolled. Voluntary informed consent was obtained from each participant. Prior to the study, all participants took part in a 20-minute theoretical session concerning different methods of airway management during
cardiopulmonary resuscitation. At the end of the training, they watched a demonstration of correct blind intubation with the use of the SALT. After that, they were allowed a 10-minute practice until they could properly apply the device. An Airway Management Trainer (Laerdal, Stavanger, Norway) was used for intubation. The trainer was placed on the floor in a bright room. All the participants performed the study intubation in two scenarios: with and without the CBRN-PPE. The order of participants and simulation scenarios was randomized by the Research Randomizer software (www.randomizer.org). The primary outcome measure was the time to intubation (TTI), that is, the time of the successful endotracheal tube placement in the trachea via the SALT. The TTI was measured from the moment when the participant took the endotracheal tube in the hand until chest rising was clearly visible in the manikin when ventilated. The secondary outcome was the success rate of the first intubation attempt. The successful intubation attempt was defined as a correct placement of the endotracheal tube in the trachea as confirmed by the inflation of both lungs during ventilation and the visualization of the tube by the principal investigator. The median TTI for blind intubation was 42.3 (interquartile range, 36-47.5) seconds for the cases with standard clothing and 51.5 (4457.5) seconds for CBRN-PPE intubations, the difference being statistically significant (P= .032). The success rate of the first intubation attempt equaled 84.0% for intubation with standard clothing and 76.0% for that with the CBRN-PPE (P= .064). The study proved that intubation through the SALT with the use of the CBRN-PPE took more time than that performed with conventional clothing. Nevertheless, further evaluation of performing blind intubation via the SALT in the clinical setting is recommended.
Sebastian Aleksandrowicz, MSc, EMT-P Polish Society of Disaster Medicine, Warsaw, Poland Marcin Madziala, MSc, EMT-P Department of Emergency Medicine, Medical University of Warsaw, Poland Corresponding author at: Department of Emergency Medicine Medical University of Warsaw, 4 Lindleya Str., 02-005, Warsaw, Poland Tel.: +48 519160829 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2016.07.037 References [1] Szarpak L, Karczewska K, Evrin T, Kurowski A, Czyzewski L. Comparison of intubation through the McGrath MAC, GlideScope, AirTraq, and miller laryngoscope by paramedics during child CPR: a randomized crossover manikin trial. Am J Emerg Med 2015;33(7):946–50. http://dx.doi.org/10.1016/j.ajem.2015.04.017. [2] Truszewski Z, Czyzewski L, Smereka J, Krajewski P, Fudalej M, Madziala M, et al. Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes. Am J Emerg Med 2016;34(9):1835–9. http://dx.doi.org/10.1016/j.ajem. 2016.06.054 [pii: S0735-6757(16)30270-4]. [3] Claret PG, Asencio R, Rogier D, Roger C, Fournier P, Tran TA, et al. Comparison of miller and Airtraq laryngoscopes for orotracheal intubation by physicians wearing CBRN protective equipment during infant resuscitation: a randomized crossover simulation study. Scand J Trauma Resusc Emerg Med 2016;24:35. http://dx.doi.org/10.1186/s13049-016-0228-1. [4] Szarpak L, Ramirez JG, Buljan D, Drozd A, Madziała M, Czyzewski L. Comparison of bone injection gun and Jamshidi intraosseous access devices by paramedics with and without chemical-biological-radiological-nuclear personal protective equipment: a randomized, crossover, manikin trial. Am J Emerg Med 2016;34(7):1307–8. http:// dx.doi.org/10.1016/j.ajem.2016.04.032. [5] Claret PG, Bobbia X, Asencio R, Sanche E, Gervais E, Roger C, et al. Comparison of the Airtraq laryngoscope versus the conventional Macintosh laryngoscope while wearing CBRN-PPE. Eur J Emerg Med 2016;23(2):119–23. http://dx.doi.org/10.1097/MEJ. 0000000000000220. [6] Kurowski A, Hryniewicki T, Czyżewski L, Karczewska K, Evrin T, Szarpak Ł. Simulation of blind tracheal intubation during pediatric cardiopulmonary resuscitation. Am J Respir Crit Care Med 2014;190(11):1315. http://dx.doi.org/10.1164/rccm.201409-1635LE.
Correspondence / American Journal of Emergency Medicine 34 (2016) 2029–2049
After finishing, the patient's fingers should be freed from the fingertraps and ice should be applied external to the splint.
Kalpit N. Shah * Andrew D. Sobel Edward Akelman Andrea Halim Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University * Corresponding author at: 593 Eddy St., Providence, RI, 02903. Tel.: +1 858 436 6070. E-mail address: [email protected] (K.N. Shah).
http://dx.doi.org/10.1016/j.ajem.2016.07.038 References [1] Ilyas AM, Jupiter JB. Distal radius fractures—classification of treatment and indications for surgery. Hand Clin 2010;26:37–42. [2] Koval K, Haidukewych GJ, Service, B, Zirgibel BJ. Controversies in the Management of Distal Radius Fractures. J Am Acad Orthop Surg 2014;22:566–75. [3] Earnshaw SA, Aladin A, Surendran S, Moran CG. Closed reduction of Colles fractures: comparison of manual manipulation and finger-trap traction. J Bone Joint Surg Am 2002;84:354–8. [4] Charnley J. The closed treatment of common fractures. Cambridge University Press; 2003[at https://books.google.com/books?id=HTiqWb530MYC]. [5] Grafstein E, Stenstrom R, Christenson J, Innes G, MacCormack R, Jackson C, et al. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures. Can J Emerg Med 2010;12:192–200. [6] Dée W, Klein W, Rieger H. Reduction techniques in distal radius fractures. Injury 2000;31:48–55 [Supple]. [7] Eichinger JK, Agochukwu U, Franklin J, Arrington ED, Bluman EM. A new reduction technique for completely displaced forearm and wrist fractures in children. J Pediatr Orthop 2011;31:e73–9.
Blind intubation through the supraglottic airway laryngopharyngeal tube with a biohazard suit To the Editor, Securing the airway belongs to the basic skills of medical personnel, including paramedics. Currently, tracheal intubation is considered the gold standard for airway management [1]. If properly performed, it isolates the respiratory tract, eliminating or significantly reducing the risk of gastric contents aspiration into the airway [2]. However, from the disaster medicine point of view, in numerous situations, because of the risk to their life and health, paramedics should perform rescue management activities using protective clothing of highest priority, i.e. the chemical, biological, radiological and nuclear personal protective equipment (CBRN-PPE) [3-5]. The use of CBRN-PPE during endotracheal intubation with direct laryngoscopy can exert a negative impact on the efficacy of intubation. A solution may be blind intubation via supraglottic airway devices [6]. The aim of the study was to evaluate the effectiveness of blind intubation through the supraglottic airway laryngopharyngeal tube (SALT) performed by paramedics with and without CBRN-PPE. This prospective, randomized crossover manikin study was reviewed and approved by the Institutional Review Board of the Polish Society of Disaster Medicine (approval No. 06.05.2016.17) and was conducted in July 2016. Twenty-five paramedics who had performed more than 30 direct laryngoscopic intubations and had more than one-year experience in the Emergency Medical Service were enrolled. Voluntary informed consent was obtained from each participant. Prior to the study, all participants took part in a 20-minute theoretical session concerning different methods of airway management during
cardiopulmonary resuscitation. At the end of the training, they watched a demonstration of correct blind intubation with the use of the SALT. After that, they were allowed a 10-minute practice until they could properly apply the device. An Airway Management Trainer (Laerdal, Stavanger, Norway) was used for intubation. The trainer was placed on the floor in a bright room. All the participants performed the study intubation in two scenarios: with and without the CBRN-PPE. The order of participants and simulation scenarios was randomized by the Research Randomizer software (www.randomizer.org). The primary outcome measure was the time to intubation (TTI), that is, the time of the successful endotracheal tube placement in the trachea via the SALT. The TTI was measured from the moment when the participant took the endotracheal tube in the hand until chest rising was clearly visible in the manikin when ventilated. The secondary outcome was the success rate of the first intubation attempt. The successful intubation attempt was defined as a correct placement of the endotracheal tube in the trachea as confirmed by the inflation of both lungs during ventilation and the visualization of the tube by the principal investigator. The median TTI for blind intubation was 42.3 (interquartile range, 36-47.5) seconds for the cases with standard clothing and 51.5 (4457.5) seconds for CBRN-PPE intubations, the difference being statistically significant (P= .032). The success rate of the first intubation attempt equaled 84.0% for intubation with standard clothing and 76.0% for that with the CBRN-PPE (P= .064). The study proved that intubation through the SALT with the use of the CBRN-PPE took more time than that performed with conventional clothing. Nevertheless, further evaluation of performing blind intubation via the SALT in the clinical setting is recommended.
Sebastian Aleksandrowicz, MSc, EMT-P Polish Society of Disaster Medicine, Warsaw, Poland Marcin Madziala, MSc, EMT-P Department of Emergency Medicine, Medical University of Warsaw, Poland Corresponding author at: Department of Emergency Medicine Medical University of Warsaw, 4 Lindleya Str., 02-005, Warsaw, Poland Tel.: +48 519160829 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2016.07.037 References [1] Szarpak L, Karczewska K, Evrin T, Kurowski A, Czyzewski L. Comparison of intubation through the McGrath MAC, GlideScope, AirTraq, and miller laryngoscope by paramedics during child CPR: a randomized crossover manikin trial. Am J Emerg Med 2015;33(7):946–50. http://dx.doi.org/10.1016/j.ajem.2015.04.017. [2] Truszewski Z, Czyzewski L, Smereka J, Krajewski P, Fudalej M, Madziala M, et al. Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes. Am J Emerg Med 2016;34(9):1835–9. http://dx.doi.org/10.1016/j.ajem. 2016.06.054 [pii: S0735-6757(16)30270-4]. [3] Claret PG, Asencio R, Rogier D, Roger C, Fournier P, Tran TA, et al. Comparison of miller and Airtraq laryngoscopes for orotracheal intubation by physicians wearing CBRN protective equipment during infant resuscitation: a randomized crossover simulation study. Scand J Trauma Resusc Emerg Med 2016;24:35. http://dx.doi.org/10.1186/s13049-016-0228-1. [4] Szarpak L, Ramirez JG, Buljan D, Drozd A, Madziała M, Czyzewski L. Comparison of bone injection gun and Jamshidi intraosseous access devices by paramedics with and without chemical-biological-radiological-nuclear personal protective equipment: a randomized, crossover, manikin trial. Am J Emerg Med 2016;34(7):1307–8. http:// dx.doi.org/10.1016/j.ajem.2016.04.032. [5] Claret PG, Bobbia X, Asencio R, Sanche E, Gervais E, Roger C, et al. Comparison of the Airtraq laryngoscope versus the conventional Macintosh laryngoscope while wearing CBRN-PPE. Eur J Emerg Med 2016;23(2):119–23. http://dx.doi.org/10.1097/MEJ. 0000000000000220. [6] Kurowski A, Hryniewicki T, Czyżewski L, Karczewska K, Evrin T, Szarpak Ł. Simulation of blind tracheal intubation during pediatric cardiopulmonary resuscitation. Am J Respir Crit Care Med 2014;190(11):1315. http://dx.doi.org/10.1164/rccm.201409-1635LE.