Comparison of supine and upright face-to-face cadaver intubation.

INTRODUCTION: Optimal patient positioning during intubation improves laryngeal view and first pass success, as well as reducing incidence of hypoxia. In certain pre-hospital situations, it may be impractical or impossible for the operator to stand behind the patient. OBJECTIVE: We compared intubation in the supine and upright face-to-face positions, with regards to time to intubate and the view of the vocal cords obtained. METHODS: This was a pilot comparison study. One investigator intubated 25 cadavers with the use of a bougie in the supine and upright face-to-face positions. Each attempt was recorded on a video laryngoscope. Recordings of each attempt were reviewed by five blinded emergency physicians, who allocated both a percentage of glottic opening (POGO) score and Cormack-Lehane (CL) grade. Time to insertion of the endotracheal tube (ETT) through the vocal cords was measured from the video. RESULTS: The median intubation time was 1 s longer for upright cadavers than for supine cadavers, with greater variation in intubation times for upright cadavers compared with supine cadavers (IQR 9.0 vs 3.5 excluding the outlier case). The mean POGO score (averaged across raters) was 4.7% lower for upright intubation attempts (excluding the outlier case) with a moderate-to-good degree of inter-rater reliability, however this difference was not statistically significant. The median CL grade (averaged across raters) was 0.2 higher for upright intubation attempts (excluding the outlier case) with a poor-to-moderate degree of inter-rater reliability, and this difference was also not statistically significant. CONCLUSIONS: This pilot study suggests that upright, face-to-face intubation may be clinically similar to supine intubation in terms of time to intubation and difficulty. Further studies utilising a larger number of operators and cadaver types are indicated.

Mapping haemodynamic changes with rapid sequence induction agents in the emergency department.

OBJECTIVE: Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. METHODS: This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability. RESULTS: From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. CONCLUSION: Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.