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.

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.