Which airways management technique is optimal for trauma patient ventilation?

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Correspondence

European Journal of Emergency Medicine2016, 23:455–462

Which airways management technique is

optimal for trauma patient ventilation?

Lukasz Szarpaka_{, Marcin Madziala}b_{and Togay Evrin}c_,a_{Department of}

Emergency Medicine, Medical University of Warsaw,b_{International Institute of}

Rescue Research and Education, Warsaw, Poland andc_{Department of}

Emergency Medicine, UFuK University Medical Faculty, Dr Ridvan Ege Education and Research Hospital, Ankara, Turkey

Correspondence to Marcin Madziala, MSc, EMT-P, International Institute of Rescue Research and Education, Trzcinska 22/78, 96-100 Skierniewice, Poland Tel: + 48 519 160 829; fax: + 48 500 186 225;

e-mail: [email protected]

Received28 October 2015 Accepted 24 November 2015

We have read the article entitled ‘In a difficult access scenario, supraglottic airway devices improve success and time to ventilation’ with great interest [1]. We wish to thank Wetsch and colleagues for their contribution with a comparison of different supraglottic airway devices (SADs) to ventilation patient interrupted in the vehicle. Without doubt the airway security– especially in the case of patients with injuries of the central nervous system, depressed mentation, respiratory distress, or for whom there is concern about protecting the airway– is a critical element of emergency measures [2]. Ventilation of a patient with SADs may be an alternative method to secure the airway in a prehospital setting, especially for individuals who do not have sufficient skills in endo-tracheal intubation. However, as indicated by numerous scientific societies, endotracheal intubation is a gold standard for airway management [3,4].

In the study of Wetsch and colleagues, the study group included 25 anesthesiologists. In Poland, as well as in many other countries, Emergency Medical Service teams are mainly composed of paramedics. In the scenario described by Wetsch and colleagues, with the need for airway management and ventilation significantly more often will meet paramedics. Therefore, we attempted to evaluate the effectiveness of various methods for airway management and ventilation performed only by para-medics. Paramedics performed airway management in a patient trapped in the driver’s seat (BMW 5; BMW Motors, Germany), with access through the driver’s open door. Thirty-five paramedics participated in our trial. To compare the simulation scenario with the research of Wetsch and colleagues, confinement was also simulated by moving the driver’s seat all the way forward and in an upright position (reclining of the seat was not allowed). The study was designed as a randomized crossover trial.

The devices used for our study were as follows:

(1) Macintosh laryngoscope, blade 3 (MAC) (HEINE Optotechnik, Munich, Germany) with a 7.5 ID endotracheal tube.

(2) ETView VivaSight SL 7.5 ID (ETView; ETView Ltd, Misgav, Israel), which is a single-lumen airway tube with an integrated high-resolution imaging camera so that we can see the image from the end of the endotracheal tube.

(3) iGel laryngeal mask (iGel, size 4; Intersurgical, St Augustin, Germany).

(4) Ambu AuraOnce laryngeal mask (Ambu, size 4; Ambu, Bad Nauheim, Germany).

A standard semi-rigid stylet was inserted into the tracheal tube when intubation was performed with the MAC or the ETView.

The primary endpoint was time taken to ventilation (TTV), which was started when the participant picked up the airway device and ended at the point of manual ventilation after the airway was secure. Correct ventila-tion could be verified by the manikin’s ventilaventila-tion indi-cators. The secondary endpoint was the rate of successful airway secure during the first attempt, which was recor-ded when the ventilation was successful.

The analysis showed that the shortest average TTV was achieved with iGel 11 [interquartile range (IQR), 9.5–15] s, followed by ETView – 13.5 (IQR, 10–16) and Ambu – 14.5 (IQR, 11–18.5) s, and the longest when using MAC – 36.4 (IQR, 29–48.5) s. A statistically sig-nificant difference was found between ETView and MAC (P< 0.001), iGel and MAC (P < 0.001), and between Ambu and MAC (P< 0.001). The success rate after the first attempt using the distinct devices varied and amounted to 77.1 versus 100, compared to 100 versus 100% (MAC vs. ETView vs. iGel vs. Ambu).

Although the shortest time required for airway manage-ment and ventilation was observed in the case of iGel, the difference in TTV with respect to ETView was not statistically significant. In addition, use of endotracheal tube ETView reduces the risk of leaks. [5]. More studies are required to confirm these results.

Acknowledgements

Author’s contributions: Conception and design: L.S., M.M., T.E.; analysis and interpretation: L.S., M.M.; Correspondence 455

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drafting the manuscript for important intellectual con-tent: L.S., M.M., T.E.

Conflicts of interest

There are no conflicts of interest.

References

1 Wetsch WA, Schneider A, Schier R, Spelten O, Hellmich M, Hinkelbein J. In a difficult access scenario, supraglottic airway devices improve success and time to ventilation. Eur J Emerg Med 2015; 22:374–376.

2 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; 190:1315.

3 Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132 (Suppl 2): S444–S464.

4 Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, et al. Adult Advanced Life Support Section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2015; 95:100–147.

5 Weber U, Oguz R, Potura LA, Kimberger O, Kober A, Tschernko E. Comparison of the i-gel and the LMA-Unique laryngeal mask airway in patients with mild to moderate obesity during elective short-term surgery. Anaesthesia 2011; 66:481–487.

Supraglottic airways in difficult access

–

confirming results in both studies

Wolfgang A. Wetsch, Andreas Schneider, Robert Schier and

Jochen Hinkelbein,Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany

Correspondence to Wolfgang A. Wetsch, MD, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Street 62, 50937 Cologne, Germany

Tel: + 49 221 478 0; fax: + 49 221 478 148 8233; e-mail: [email protected]

Received8 November 2015 Accepted 24 November 2015

We wish to thank Szarpak and colleagues for their letter to the editor [1] and their comments on our study [2]. We are pleased to see that the data presented in their letter are completely in congruence with our own results. Their data support the validity of the results of both studies, which were designed and carried out completely inde-pendently in a very similar setting.

However, it must be kept in mind that the results of both studies were gathered in models – that is, a manikin model of a human accident victim in a car with only simulated entrapment– and not in real patients. A model can always provide only a surrogate of a real patient and does not consider anatomical variations as they may be present in human beings. Hence, data gathered from studies using manikins must be interpreted with care and cannot be extrapolated uncritically to a real patient setting [3,4].

Furthermore, Szarpak and colleagues comment that a study with paramedics would rather represent the ‘real-life setting’ than our study with an anaesthesiologist [2]. On this point, we strongly disagree with the authors, at least for those countries with a physician-staffed emer-gency medical service system. Airway management in these countries is rarely performed by less experienced staff, and among a few others, an anaesthesiologist is a typical emergency medical service staff physician [3].

Acknowledgements

Conflicts of interest

J.H. has received travel expenses from Ambu GmbH, Germany, during the last 5 years. For the remaining authors there are no conflicts of interest.

References

1 Szarpak L, Madziala M, Evrin T. Which airway management technique is optimal for trauma patient ventilation? Eur J Emerg Med 2016; 23:455–456. 2 Wetsch WA, Schneider A, Schier R, Spelten O, Hellmich M, Hinkelbein J. In a difficult access scenario, supraglottic airway devices improve success and time to ventilation. Eur J Emerg Med 2015; 22:374–376.

3 Deakin CD, Murphy D, Couzins M, Mason S. Does an advanced life support course give non-anaesthetists adequate skills to manage an airway? Resuscitation 2010; 81:539–543.

4 Russo SG, Bollinger M, Strack M, Crozier TA, Bauer M, Heuer JF. Transfer of airway skills from manikin training to patient: success of ventilation with facemask or LMA-Supreme(TM) by medical students. Anaesthesia 2013; 68:1124–1131.

A proposal algorithm for patients presenting

to the Emergency Department with renal colic

Marco Fiore,Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy

Correspondence to Marco Fiore, MD, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy

Tel: + 39 081 566 5180; fax: + 39 081 455 426; e-mail: [email protected] Received17 November 2015 Accepted 10 December 2015

I read with great interest the review outlining appropriate diagnostic strategies with lab work and imaging for emergency presentation of acute flank pain in patients presenting to the Emergency Department (ED), pub-lished recently in the European Journal of Emergency Medicine [1]. The authors proposed plain radiography (colloquially called kidney–ureters–bladder radiographs) as the first imaging technique; this may help identify an opacity representative of a stone. Ultrasound provides a more directed and comprehensive anatomic assessment compared with kidney–ureters–bladder, but it was con-cluded that it is not optimal as the only means of inves-tigation in the incident renal colic setting and that computed tomography (CT) is the imaging modality of choice in the investigation of renal colic.

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