Engagement of the Median Glossoepiglottic Fold and Laryngeal View During Emergency Department Intubation.

Study Objective: When using a standard geometry laryngoscope, experts recommend engaging the hyoepiglottic ligament-a ligament deep to the vallecula not visible to the intubator. The median glossoepiglottic fold (hereafter termed midline vallecular fold) is a superficial mucosal structure, visible to the intubator, that lies in the midline of the vallecula. We aimed to determine whether engaging the midline vallecular fold with a standard geometry blade tip during orotracheal intubation improved laryngeal visualization.

The High-Risk Airway.

The high-risk airway is a common presentation and a frequent cause of anxiety for emergency physicians. Preparation and planning are essential to ensure that these challenging situations are managed successfully. Difficult airways typically present as either physiologic or anatomic, each type requiring a specialized approach.

The Cric-Key™ and Cric-Knife™: a combined tube-introducer and scalpel-hook open cricothyrotomy system.

The author describes a cricothyrotomy system that consists of two devices that, packaged together, are labeled the Control-Cric™ system. The Cric-Key™ was invented to verify tracheal location during surgical airway procedures?without the need for visualization, aspiration of air, or reliance on clinicians? fine motor skills. The Cric-Knife™ combines a scalpel with an overlying sliding hook to facilitate a smooth transition from membrane incision to hook insertion and tracheal control.

Preoxygenation and prevention of desaturation during emergency airway management.

Patients requiring emergency airway management are at great risk of hypoxemic hypoxia because of primary lung pathology, high metabolic demands, anemia, insufficient respiratory drive, and inability to protect their airway against aspiration. Tracheal intubation is often required before the complete information needed to assess the risk of periprocedural hypoxia is acquired, such as an arterial blood gas level, hemoglobin value, or even a chest radiograph. This article reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation.

The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices.

Intubation research on both direct laryngoscopy and alternative intubation devices has focused on laryngeal exposure and not the mechanics of actual endotracheal tube delivery or insertion. Although there are subtleties to tracheal intubation with direct laryngoscopy, the path of tube insertion and the direct line of sight are relatively congruent. With alternative intubation devices, this is not the case.

Use of a battery-operated needle driver for intraosseous access by novice users: skill acquisition with cadavers.

Study Objectives: We determine skill acquisition and performance by using a battery-operated, intraosseous needle driver in cadavers.

Methods: This was a prospective study of the EZ-IO, a battery-operated intraosseous needle driver (Vidacare Corp). Operators received a 5-minute presentation (with 1 insertion demonstration) and then performed 3 tibial insertions on a cadaver.

Light intensity of curved laryngoscope blades in Philadelphia emergency departments.

Study Objective: Laryngoscopy and tracheal intubation requires laryngeal exposure and illumination. The objective of this study is to assess variation in laryngoscope lights across different emergency departments (EDs).

Methods: A convenience sample of 3 Mac #4 blade and handle pairs in each of 17 Philadelphia area EDs was tested with a digital light meter to derive the median lux at the distal tip.

Stylet bend angles and tracheal tube passage using a straight-to-cuff shape.

Objectives: Malleable stylets improve maneuverability and control during tube insertion, but after passage through the vocal cords the stiffened tracheal tube may impinge on the tracheal rings, preventing passage. The goal of this study was to assess insertion difficulty with styletted tubes of different bend angles.

Methods: Tube passage was assessed with four different bend angles (25 degrees, 35 degrees, 45 degrees, and 60 degrees) using straight-to-cuff-shaped tubes.

Design rationale and intended use of a short optical stylet for routine fiberoptic augmentation of emergency laryngoscopy.

Patient safety in emergency airway management has traditionally relied upon prediction of difficult laryngoscopy and alternative intubation devices. Unfortunately, screening tests for difficult laryngoscopy have poor predictive value, and alternative devices are often not suitable for emergency airways. RSI performed with hit or miss repetitive laryngoscopy followed by delayed deployment of rarely used rescue devices is inherently hazardous.

Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.

Study Objective: External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view.

Methods: This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004.

Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions.

Background: The effect of patient position on the view obtained during laryngoscopy was investigated.

Methods: 60 morbidly obese patients undergoing elective bariatric were studied. Patients were randomly assigned into one of two groups.

Limitations of difficult airway prediction in patients intubated in the emergency department.

Study Objective: Physiognomic assessment of difficult laryngoscopy before rapid sequence intubation has been advocated for all emergency department (ED) intubations. The study objectives were to evaluate whether Mallampati scores, thyromental distance, and neck mobility could have been assessed in non-cardiac arrest ED-intubated patients and determine whether such tests would have been feasible in our rapid sequence intubation-associated laryngoscopy failures.

Methods: We retrospectively reviewed 37 months of ED intubations using prospectively collected data from electronic medical records, critical care flow sheets, and a trauma registry.

Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.

Study Objective: We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis.

Methods: Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days.

Patient safety in emergency airway management and rapid sequence intubation: metaphorical lessons from skydiving.

Concern about patient safety and failed rapid sequence intubation has led to an increased awareness of potentially difficult laryngoscopy situations and algorithms promoting techniques in awake patients. Given the low overall incidence of failed laryngoscopy, however, prediction of difficult laryngoscopy has poor positive predictive value and uncertain clinical utility, especially in emergency settings. Non-rapid sequence intubation approaches have comparatively lower chances of intubation success, require more time, and are associated with more complications.

Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation.

Study Objective: The objective of this study was to determine the effect of increasing head elevation and neck flexion on the quality of laryngeal view during laryngoscopy.

Methods: Laryngoscopy with a straight blade was performed on 7 fresh human cadavers. Laryngeal views were recorded with the direct laryngoscopy video system, and the laryngoscopy angle was measured throughout the procedure with an angle finder attached to the handle of the laryngoscope.

Bimanual laryngoscopy: a videographic study of external laryngeal manipulation by novice intubators.

Study Objective: We perform a videographic analysis of external laryngeal manipulation (ELM) by novice intubators using a direct laryngoscopic imaging system and a validated means of assessing laryngeal view (percentage of glottic opening [POGO] score).

Methods: Nine first-year emergency medicine residents performed a total of 484 laryngoscopies during a 1-year study period, of which 271 were videotaped. Of this convenience sample, cases were included in the study if the initial laryngeal view had a POGO score of less than 50% and the quality of video imaging permitted POGO scoring before and after application of ELM.