Comparing Direct and Video Laryngoscopy Skills Between Resident and Attending Emergency Physicians.

Introduction Advances in airway technology, in particular video laryngoscopy, are forcing attending emergency medicine physicians to master and maintain innovative airway skills. This study compares intubation times and other airway outcomes between resident and attending physicians using direct and video laryngoscopy in a mannequin model. Methods Fifty emergency medicine resident and attending physicians were asked to intubate a mannequin, using direct laryngoscopy, a C-MAC standard geometry blade, and a GlideScope hyperangulated blade. Intubation times, intubation success and accuracy, Cormack-Lehane grades, and the physician's opinion of the ease of the intubation were recorded for each intubation. Results Second-year residents had significantly quicker intubation times than attending physicians with all 3 intubation modalities. They also outperformed the interns when using the C-MAC standard geometry blade and had faster intubation times compared to third-year residents using direct laryngoscopy. When using the GlideScope hyperangulated blade, all 3 years of residents had lower intubation times compared to attending physicians and they were more accurate with endotracheal tube placement. Unlike the second-year residents, the third-year residents were not faster at direct laryngoscopy compared to the attending physicians. Conclusion Second-year residents outperformed their resident counterparts and the attending physicians with improved intubation times. Nontraditional intubation techniques associated with the GlideScope hyperangulated blade must be learned, practiced, and maintained by attending physicians, which is reflected in their longer intubation times compared to the residents. In addition, DL skills can deteriorate among resident physicians if they are not used on a regular basis.

Effects of cardiopulmonary resuscitation on direct versus video laryngoscopy using a mannequin model.

INTRODUCTION: During the last decade, guidelines for cardiopulmonary resuscitation has shifted, placing chest compressions and defibrillation first and airway management second. Physicians are being forced to intubate simultaneously with uninterrupted, high quality chest compressions. Using a mannequin model, this study examines the differences between direct and video laryngoscopy, comparing their performance with and without simultaneous chest compressions. METHODS: Fifty emergency medicine physicians were randomly assigned to intubate a mannequin six times, using direct laryngoscopy (DL) and with two video laryngoscopy (VL) systems, a C-MAC traditional Macintosh blade and a GlideScope hyperangulated blade, with and without simultaneous chest compressions. A total of 300 intubations were completed and variables including intubation times, accuracy, difficulty, success rates and glottic views were recorded. RESULTS: The C-MAC VL system resulted in quicker intubations compared to DL (p = 0.007) and the GlideScope VL system (p = 0.039) during active chest compressions. Compared to DL, intubations were rated easier for both the C-MAC (p < 0.0001) and the GlideScope (p < 0.0001). Intubation failure rates were also higher when DL was used compared to either the C-MAC or GlideScope (p = 0.029). VL devices provided a superior overall Cormack-Lehane grade view compared to DL (p < 0.0001). The presence of chest compressions significantly impaired Cormack-Lehane views during direct laryngoscopy (p = 0.007). Chest compressions made the intubation more difficult under DL (p = 0.002) and when using the C-MAC (p = 0.031). Chest compressions also made ETT placement less accurate when using DL (p = 0.004). CONCLUSION: Using a mannequin model, the C-MAC conventional VL blade resulted in decrease intubation times compared with DL or the GlideScope hyperangulated VL blade system. Overall, VL out performed DL in terms of providing a superior glottic view, minimizing failed attempts, and improving physician's overall perception of intubation difficulty. Chest compressions resulted in worse Cormack-Lehane views and higher rates of inaccurate endotracheal tube placement with DL, compared to VL.

The REAL CRIC Trainer: Instructions for Building an Inexpensive, Realistic Cricothyrotomy Simulator With Skin and Tissue, Bleeding, and Flash of Air.

BACKGROUND: Surgical cricothyrotomy is a rare procedure but it must be mastered by any physician who is involved in advanced airway management. Lack of experience and practice, the high-stress nature of a "can't intubate, can't oxygenate" emergency, and the unavailability of realistic simulators all contribute to physician hesitance and inaptitude while employing cricothyrotomy during difficult and failed airways. The REAL CRIC Trainer was created to alleviate some of the barriers surrounding a surgical airway. It is designed to provide the user an affordable, easy to replicate, reusable, and extremely realistic experience in cricothyrotomy to prepare for this rare event. DISCUSSION: The REAL CRIC Trainer uses a 3-dimensional printed tracheal model that is covered with pork belly skin, replicating human neck tissue. Red dyed normal saline is connected to the pork belly using intravenous tubing to simulate bleeding as an incision is made into the porcine skin. A bag-valve-mask connected to an endotracheal tube and to the trachea model will simulate breathing and replicate the puff of air experienced as the cricothyroid membrane is pierced with a scalpel. This simulator is cost effective and easy to replicate. Detailed step-by-step instructions are provided so that physicians working in any specialty involved in advanced airway management can easily recreate this trainer. CONCLUSIONS: This simulator makes it practical for physicians in a variety of clinical settings to incorporate its use into regular practice sessions, thereby assuring that physicians are ready to perform an emergent cricothyrotomy if necessary.

Using Ultrasonography to Assess the Effectiveness of Cricoid Pressure on Esophageal Compression.

BACKGROUND: Cricoid pressure during intubation has been used for decades as a way to potentially occlude the esophagus to avoid aspiration of gastric contents. However, recent evidence has questioned the effectiveness of this maneuver. OBJECTIVE: This study uses a noninvasive modality, ultrasonography, to determine the anatomic position of the cricoid cartilage and the esophagus and examines the effectiveness of cricoid pressure on esophageal compression. METHODS: Ultrasound imaging was used to describe the anatomic relationship of the esophagus to the trachea as either being directly behind the trachea, partially behind the trachea, or completely lateral to the trachea. These relationships were described with and without cricoid pressure. Participants were also asked to swallow a carbonated beverage with and without cricoid pressure to help visualize the exact position of the esophagus and to see whether cricoid pressure actually occluded the esophagus and the passage of the liquid. RESULTS: Without cricoid pressure, 20% of the esophagi laid directly behind the trachea, 60% partially behind the trachea, and 20% completely lateral to the left of the trachea. When cricoid pressure was applied, the esophagus shifted laterally to the left in 50% of the subjects and remained directly behind the trachea in only 4% of our entire study group. In addition, all of the participants were able to swallow liquid with cricoid pressure applied. CONCLUSIONS: This study highlights the potential ineffectiveness of cricoid pressure on esophageal compression, calling into question the utility of this maneuver.

Comparing the Effectiveness of a Novel Suction Set-up Using an Adult Endotracheal Tube Connected to a Meconium Aspirator vs. a Traditional Yankauer Suction Instrument.

BACKGROUND: It has been suggested that an adult 8.0 endotracheal tube (ETT) connected to a neonatal meconium aspirator would improve suctioning during emergent endotracheal intubation compared to the Yankauer suction instrument, the standard tool used by emergency physicians. OBJECTIVES: This study was designed to compare the effectiveness of a Yankauer vs. an ETT-meconium aspirator set-up in suctioning liquids of different viscosities. METHODS: The Yankauer and ETT-meconium aspirator device underwent a head-to-head timed comparison, suctioning 250 mL of three different fluids, varying in viscosity. The first comparison test used tap water to represent simple oral secretions. The second comparison test used porcine whole blood as a proxy for human blood. The third comparison test used a coarsely blended mixture of a hamburger, French fries, and a soda to simulate emesis from a recently ingested meal. Five separate time trials were conducted for each liquid and for each suction device. RESULTS: The ETT-meconium aspirator device compared to the Yankauer suctioned faster in both the water comparison test (mean = 2.6 s vs. 3.4 s; p < 0.001) and the porcine whole blood comparison test (mean = 2.9 s vs. 4.3 s; p = 0.0015). In the emesis trial, the Yankauer immediately clogged, whereas the ETT-meconium aspirator apparatus managed to suction an average of 90 mL prior to clogging. CONCLUSION: Compared to the Yankauer, an adult 8.0 ETT connected to a meconium aspirator was superior in suctioning liquids of varying viscosities and should be considered when encountering a difficult airway due to copious secretions, blood, or emesis.

Image diagnosis: arachnoid cyst.

A 14-year-old boy presented with 3 months of generalized headache that had increased in intensity and frequency with associated light-headedness. Primary arachnoid cysts result from developmental abnormalities; more rare secondary cysts develop as a result of head injury, meningitis, tumors, or as a complication of brain surgery.

Rare case of myocardial infarction in a 19-year-old caused by a paradoxical coronary artery embolism.

This case focuses on a 19-year-old man who developed an inferior ST-segment elevation myocardial infarction as a result of a previously undetected large atrial septal defect. This cardiac anomaly facilitated the transport of a paradoxical embolism that occluded the right coronary artery.

Case report: dealing with a ventilation complication after successful cricothyrotomy.

BACKGROUND: Cricothyrotomy is a rare procedure in the Emergency Department, but necessary in cases where endotracheal intubation has failed and the patient cannot be ventilated. After establishing a cricothyrotomy, ventilation may be difficult, depending on the etiology of the patient's respiratory failure. OBJECTIVES: This case highlights a successful cricothyrotomy that needed further direct intervention to correct an air leak from the patient's mouth. CASE REPORT: A novel double-bag technique (DBT), where an Ambu(®) bag (Ambu Inc., Glen Burnie, MD) was connected to the cricothyrotomy catheter and another Ambu bag placed over the mouth and nose, was employed to help solve the post-cricothyrotomy air leak problem. CONCLUSION: It was only after this DBT technique was initiated that we were able to properly ventilate and oxygenate the patient.

The prevalence of methicillin-resistant Staphylococcus aureus on inanimate objects in an Urban Emergency Department.

BACKGROUND: There is a rising prevalence of both hospital-acquired and community-associated strains of methicillin-resistant Staphylococcus aureus (MRSA) infections. Both strains are found in patients presenting to emergency departments (EDs). OBJECTIVE: The purpose of this study was to identify objects in the ED that might contribute to the spread of MRSA. METHODS: This was a cross-sectional prevalence study in which culture swabs were taken from 20 different objects in a large urban ED between May and August 2006. The objects were identified a priori, and included common items found in an ED. Items ranging from computers to telephones, desktop surfaces, security door keypads, and ultrasound probes were included in the study. Each item was cultured twice, on separate days, for a total of 40 samples. The samples were screened for the presence of MRSA, and positive samples underwent additional susceptibility analysis. RESULTS: Only one sample of 40, from the ambulance bay security door keypad, was positive for MRSA. Thus, the prevalence of MRSA was 2.5%. The single strain isolated was resistant to clindamycin, erythromycin, oxacillin, and penicillin. CONCLUSION: MRSA does not seem to thrive on inanimate objects found in the ED. Routine cleaning measures in an urban ED must include all areas of medical personnel use, including areas outside of the department utilized by non-ED workers.