Conclusion Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. (BMJ 2010; 341:c5943 )

then get a chest xray

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Roc Vs. Sux

Same when dosed high (Academic Emergency Medicine Volume 18, Issue 1, pages 1014, January 2011)

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Mask Ventilation

When rocuronium was adminsitered compared to placebo, mask ventilation got better (Anaesthesia, 2011, 66, pages 163167)

You need two hands on the mask (One Hand, Two Hands, or No Hands)

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Gastric Tubes

My practice is to place gastric tubes prior to intubating GI bleeders or alcoholics. The question is whether this decreases the esophageal sphincter opening pressure

Answer is it doesn’t (Gastroenterology 1976;70:301; Arch Surg 1978;113:721)

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Ketamine-Only Intubation

Emerg Med J 2011;28:521 71 Patients, 18 didn’t get paralysis

Injury 1997;28:41

Am J Emerg Med 2007;25:977

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Complications of the airway management of the critically Ill

Start worrying at 70%, pt may die below 60% (J Intensive Care Med 2007 22: 208 Mort)

Hemodynamics (J Intensive Care Med 2007 22: 157)

Complications rise at the 3 mor more attempt mark (Anesth Analg 2004;99:60713)

Tube passage attempts are worse than blade passage attempts

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Depth Of Tube Insertion

BMJ. 2010; 341: c5943.

Conclusion Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements

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Prehospital Intubations

Resuscitation. 2011 Apr;82(4):378-85. Epub 2011 Feb 1. Out-of-hospital airway management in the United States. Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM.

Source

Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, United States. hwang@uabmc.edu

Abstract

OBJECTIVE:

Prior studies describe airway management by single EMS agencies, regions or states. We sought to characterize out-of-hospital airway management interventions, outcomes and complications across the United States.

METHODS:

Using the 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states, we identified patients receiving advanced airway management, including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and open). We examined airway management success and complications in the full cohort and in key subsets (cardiac arrest, non-arrest medical, non-arrest injury, children <10 and 10-19 years, rapid-sequence intubation (RSI), population setting and US census region). We analyzed the data using descriptive statistics.

RESULTS:

Among 4,383,768 EMS activations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1-77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children <10 years 295/397 (74.3%), children 10-19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapid-sequence intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000).

CONCLUSIONS:

In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management.

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