Prehospital SALAD Airway Technique in an Adolescent with Penetrating Trauma Case Report.

We present a case of an adolescent patient with a penetrating gunshot wound to the mouth requiring endotracheal intubation via rapid sequence intubation in the prehospital setting. The team used video laryngoscopy (VL) to secure the airway; however, continuous bloody secretions increased the complexity of the procedure and required the application of the Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) method to facilitate intubation. By utilizing the SALAD procedure, the field of view on the VL camera remained unobscured, and the patient's airway remained clear, allowing for an uneventful intubation procedure. No episodes of hypoxia, hypotension, bradycardia, or obvious clinical signs of pulmonary aspiration occurred during the procedure. The patient was transported to a local Pediatric Level I trauma center, where he underwent emergent surgery to repair an esophageal laceration and was discharged to home 40 days later. This case highlights the importance of deliberate and proactive management of the contaminated airway in the prehospital setting. The SALAD technique replaces the Yankauer suction catheter with a larger bore suction catheter in conjunction with VL to perform gross decontamination of the mouth and airway before attempting intubation. This is followed by permanently placing the large bore suction catheter under constant suction in the posterior pharynx or esophagus to keep the VL camera unobscured by vomit or blood to facilitate intubation. After the intubation, the suction catheter may be removed unless ongoing suction is required. Keeping the VL camera unobscured during the procedure may improve first-pass intubation success rate.

Modified cadaver technique to simulate contaminated airway scenarios to train medical providers in suction-assisted laryngoscopy and airway decontamination.

Simulation training plays a vital role in modern medical education, fostering safe skill development. Task-trainer manikin and cadaveric airway management training (CAMT) offer realistic airway management practice. Simulation allows learners the opportunity to manage high-risk, low-frequency scenarios, including difficult airways and massive airway contamination, common in emergent airway management. The suction-assisted laryngoscopy and airway decontamination (SALAD) technique was developed to address massive airway contamination. This paper describes two methods to simulate massive airway contamination utilizing cadavers. We detail our techniques for both esophageal and nasopharyngeal delivery of simulated airway contaminant. Nasopharyngeal delivery was less invasive and required less time to set up. Utilizing cadavers to simulate massive airway contamination in CAMT provides learners with tools to manage airway complications effectively, enhancing readiness for complex airway challenges while promoting patient safety in clinical practice.

Compromised cardiopulmonary resuscitation quality due to regurgitation during endotracheal intubation: a randomised crossover manikin simulation study.

BACKGROUND: Regurgitation is a complication common during cardiopulmonary resuscitation (CPR). This manikin study evaluated the effect of regurgitation during endotracheal intubation on CPR quality. METHODS: An airway-CPR manikin was modified to regurgitate simulated gastric contents into the oropharynx during chest compression during CPR. In total, 54 emergency medical technician-paramedics were assigned to either an oropharyngeal regurgitation or clean airway scenario and then switched to the other scenario after finishing the first. The primary outcomes were CPR quality metrics, including chest compression fraction (CCF), chest compression depth, chest compression rate, and longest interruption time. The secondary outcomes were intubation success rate and intubation time. RESULTS: During the first CPR-intubation sequence, the oropharyngeal regurgitation scenario was associated with a significantly lower CCF (79.6% vs. 85.1%, P < 0.001), compression depth (5.2 vs. 5.4 cm, P < 0.001), and first-pass success rate (35.2% vs. 79.6%, P < 0.001) and greater longest interruption duration (4.0 vs. 3.0 s, P < 0.001) than the clean airway scenario. During the second and third sequences, no significant difference was observed in the CPR quality metrics between the two scenarios. In the oropharyngeal regurgitation scenario, successful intubation was independently and significantly associated with compression depth (hazard ratio = 0.47, 95% confidence interval, 0.24-0.91), whereas none of the CPR quality metrics were related to successful intubation in the clean airway scenario. CONCLUSION: Regurgitation during endotracheal intubation significantly reduces CPR quality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05278923 , March 14, 2022.

Randomized Comparison of Two New Methods for Chest Compressions during CPR in Microgravity-A Manikin Study.

BACKGROUND: Although there have been no reported cardiac arrests in space to date, the risk of severe medical events occurring during long-duration spaceflights is a major concern. These critical events can endanger both the crew as well as the mission and include cardiac arrest, which would require cardiopulmonary resuscitation (CPR). Thus far, five methods to perform CPR in microgravity have been proposed. However, each method seems insufficient to some extent and not applicable at all locations in a spacecraft. The aim of the present study is to describe and gather data for two new CPR methods in microgravity. MATERIALS AND METHODS: A randomized, controlled trial (RCT) compared two new methods for CPR in a free-floating underwater setting. Paramedics performed chest compressions on a manikin (Ambu Man, Ambu, Germany) using two new methods for a free-floating position in a parallel-group design. The first method (Schmitz-Hinkelbein method) is similar to conventional CPR on earth, with the patient in a supine position lying on the operator's knees for stabilization. The second method (Cologne method) is similar to the first, but chest compressions are conducted with one elbow while the other hand stabilizes the head. The main outcome parameters included the total number of chest compressions (n) during 1 min of CPR (compression rate), the rate of correct chest compressions (%), and no-flow time (s). The study was registered on clinicaltrials.gov (NCT04354883). RESULTS: Fifteen volunteers (age 31.0 ± 8.8 years, height 180.3 ± 7.5 cm, and weight 84.1 ± 13.2 kg) participated in this study. Compared to the Cologne method, the Schmitz-Hinkelbein method showed superiority in compression rates (100.5 ± 14.4 compressions/min), correct compression depth (65 ± 23%), and overall high rates of correct thoracic release after compression (66% high, 20% moderate, and 13% low). The Cologne method showed correct depth rates (28 ± 27%) but was associated with a lower mean compression rate (73.9 ± 25.5/min) and with lower rates of correct thoracic release (20% high, 7% moderate, and 73% low). CONCLUSIONS: Both methods are feasible without any equipment and could enable immediate CPR during cardiac arrest in microgravity, even in a single-helper scenario. The Schmitz-Hinkelbein method appears superior and could allow the delivery of high-quality CPR immediately after cardiac arrest with sufficient quality.

Novel Technologies and Techniques for Prehospital Airway Management: An NAEMSP Position Statement and Resource Document.

Novel technologies and techniques can influence airway management execution as well as procedural and clinical outcomes. While conventional wisdom underscores the need for rigorous scientific data as a foundation before implementation, high-quality supporting evidence is frequently not available for the prehospital setting. Therefore, implementation decisions are often based upon preliminary or evolving data, or pragmatic information from clinical use. When considering novel technologies and techniques. NAEMSP recommends:Prior to implementing a novel technology or technique, a thorough assessment using the best available scientific data should be conducted on the technical details of the novel approach, as well as the potential effects on operations and outcomes.The decision and degree of effort to adopt, implement, and monitor a novel technology or technique in the prehospital setting will vary by the quality of the best available scientific and clinical information:• Routine use - Technologies and techniques with ample observational but limited or no interventional clinical trial data, or with strong supporting in-hospital data. These techniques may be reasonably adopted in the prehospital setting. This includes video laryngoscopy and bougie-assisted intubation. • Limited use - Technologies and techniques with ample pragmatic clinical use information but limited supporting scientific data. These techniques may be considered in the prehospital setting. This includes suction-assisted laryngoscopy and airway decontamination and cognitive aids. • Rare use - Technologies and techniques with minimal clinical use information. Use of these techniques should be limited in the prehospital setting until evidence exists from more stable clinical environments. This includes intubation boxes.The use of novel technologies and techniques must be accompanied by systematic collection and assessment of data for the purposes of quality improvement, including linkages to patient clinical outcomes.EMS leaders should clearly identify the pathways needed to generate high-quality supporting scientific evidence for novel technologies and techniques.

Using supraglottic airways by paramedics for airway management in analogue microgravity increases speed and success of ventilation.

In the next few years, the number of long-term space missions will significantly increase. Providing safe concepts for emergencies including airway management will be a highly challenging task. The aim of the present trial is to compare different airway management devices in simulated microgravity using a free-floating underwater scenario. Five different devices for airway management [laryngeal mask (LM), laryngeal tube (LT), I-GEL, direct laryngoscopy (DL), and video laryngoscopy (VL)] were compared by n = 20 paramedics holding a diving certificate in a randomized cross-over setting both under free-floating conditions in a submerged setting (pool, microgravity) and on ground (normogravity). The primary endpoint was the successful placement of the airway device. The secondary endpoints were the number of attempts and the time to ventilation. A total of 20 paramedics (3 female, 17 male) participated in this study. Success rate was highest for LM and LT and was 100% both during simulated microgravity and normogravity followed by the I-GEL (90% during microgravity and 95% during normogravity). However, the success rate was less for both DL (60% vs. 95%) and VL (20% vs. 60%). Fastest ventilation was performed with the LT both in normogravity (13.7 ± 5.3 s; n = 20) and microgravity (19.5 ± 6.1 s; n = 20). For the comparison of normogravity and microgravity, time to ventilation was shorter for all devices on the ground (normogravity) as compared underwater (microgravity). In the present study, airway management with supraglottic airways and laryngoscopy was shown to be feasible. Concerning the success rate and time to ventilation, the optimum were supraglottic airways (LT, LM, I-GEL) as their placement was faster and associated with a higher success rate. For future space missions, the use of supraglottic airways for airway management seems to be more promising as compared to tracheal intubation by DL or VL.

Time to ventilation and success rate of airway devices in microgravity: A randomized crossover manikin-trial using an underwater setting.

BACKGROUND: Medical support for space exploration missions must prepare for severe medical events in conditions of microgravity. A key component to managing these events is techniques of airway management. The aim of the present trial is to compare airway management devices in simulated microgravity. METHODS: In this randomized cross-over trial (RCT), four different devices were compared under simulated microgravity conditions utilizing a neutrally buoyant free-floating underwater manikin and poolside in normal gravity (control group). The primary endpoint was the successful placement of the airway device. The secondary endpoints were the number of attempts and the duration of each attempt. RESULTS: A total of 20 participants performed placement of each device in both gravity conditions in an Airway mannequin. The fastest time to initial ventilation in simulated microgravity was possible with the laryngeal tube (18.9 ± 8 seconds) followed by laryngeal mask (20.1 ± 9 seconds). The I-gel® supraglottic airway device required substantially more time for successful insertion in simulated microgravity (35.4 ± 25 seconds) as did endotracheal tube intubation by direct laryngoscopy (70.4 ± 35 seconds). Simulated microgravity conditions prolonged time to initial ventilation by 3.3 seconds (LM), 3.9 seconds (LT), 19.9 seconds (I-gel) and 43.1 seconds (endotracheal intubation, ETI) when compared to poolside attempts in normogravity. CONCLUSION: In simulated microgravity conditions, use of the laryngeal tube or laryngeal mask provided the quickest time to initial ventilation, without deliberate tethering of the mannequin and rescuer to a fixed surface. Endotracheal intubation required significantly longer procedure times and, thus, was considered insufficient for clinical use in microgravity.

Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management.

Emergency airway management is often complicated by the presence of blood, emesis or other contaminants in the airway. Traditional airway management education has lacked task-specific training focused on mitigating massive airway contamination. The Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) technique was developed in order to address the problem of massive airway contamination both in simulation training and in vivo. We review the evidence describing the dangers associated with airway contamination, and describe the SALAD technique in detail.

A pilot study of improvised CPAP (iCPAP) via face mask for the treatment of adult respiratory distress in low-resource settings.

BACKGROUND: Continuous positive airway pressure (CPAP) is a mode of non-invasive ventilation used to treat a variety of respiratory conditions in the emergency department and intensive care unit. In low-resource settings where ventilators are not available, the ability to improvise a CPAP system from locally available equipment would provide a previously unavailable means of respiratory support for patients in respiratory distress. This manuscript details the design of such a system and its performance in healthy volunteers. METHODS: An improvised CPAP system was assembled from standard emergency department equipment and tested in 10 healthy volunteers (6 male, 4 female; ages 29-33). The system utilizes a water seal and high-flow air to create airway pressure; it was set to provide a pressure of 5 cmH2O for the purposes of this pilot study. Subjects used the system in a monitored setting for 30 min. Airway pressure, heart rate, oxygen saturation, and end-tidal CO2 were monitored. Comfort with the device was assessed via questionnaire. RESULTS: The system maintained positive airway pressure for the full trial period in all subjects, with a mean expiratory pressure (EP) of 5.1 cmH2O (SD 0.7) and mean inspiratory pressure (IP) of 3.2 cmH2O (SD 0.8). There was a small decrease in average EP (5.28 vs 4.88 cmH2O, p = 0.03) and a trend toward decreasing IP (3.26 vs 3.07 cmH2O, p = 0.22) during the trial. No significant change in heart rate, O2 saturation, respiratory rate, or end-tidal CO2 was observed. The system was well tolerated, ranked an average of 4.0 on a 1-5 scale for comfort (with 5 = very comfortable). CONCLUSIONS: This improvised CPAP system maintained positive airway pressure for 30 min in healthy volunteers. Use did not cause tachycardia, hypoxia, or hypoventilation and was well tolerated. This system may be a useful adjunctive treatment for respiratory distress in low-resource settings. Further research should test this system in settings where other positive pressure modalities are not available.

Visually guided TEE probe insertion, making a case based on anatomic variation: A cadaveric study.

AIMS: The variations in upper esophageal anatomy currently are unknown. This study was carried out to evaluate this variation and assess its impact on transesophageal echocardiography probe insertion. METHODS: We included 9 consecutive cadavers studied at the University of Maryland School of Medicine's Clinical Surgical Laboratory. Each cadaver was first intubated blindly by an echocardiographer (KAA) and then under direct vision with a UE Medical VL 400 video laryngoscope (Newton, MA) by an anesthesiologist (JD). RESULTS: The visually guided method took a shorter average time (19.4 ± 13.4 seconds) and fewer passes (2.4 ± 2.1 passes) than blind insertion (30.3 ± 19.1 seconds, 5.3 ± 3.3 passes). None of the cadavers had the esophagus located directly posterior to the trachea. The esophageal hiatus was posterior and to the right of the trachea in most (n = 6); in these, the traditional "forward" jaw thrust helped to open the esophageal hiatus. Two cadavers had the esophagus and trachea located almost side by side, and in these the "forward" jaw thrust method failed. Instead, the jaw needed to be pulled to the left in order to advance the probe. CONCLUSION: This is the first study to describe anatomic variations in the location of and relationship between the upper esophageal sphincter and the larynx for the purpose of transesophageal echocardiography probe insertion. Awareness of the side-by-side anatomic variation can help to improve esophageal intubation by prompting the use of a new "pull to the side" technique instead of the traditional "forward" jaw thrust.

Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System.

INTRODUCTION: We present a novel airway simulation tool that recreates the dynamic challenges associated with emergency airways. The Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) simulation system trains providers to use suction to manage emesis and bleeding complicating intubation. METHODS: We modified a standard difficult-airway mannequin head (Nasco, Ft. Atkinson, WI) with hardware-store equipment to enable simulation of vomiting or hemorrhage during intubation. A pre- and post-survey was used to assess the effectiveness of the SALAD simulator. We used a 1-5 Likert scale to assess confidence in managing the airway of a vomiting patient and comfort with suction techniques before and after the training exercise. RESULTS: Forty learners participated in the simulation, including emergency physicians, anesthesiologists, paramedics, respiratory therapists, and registered nurses. The average Likert score of confidence in managing the airway of a vomiting or hemorrhaging patient pre-session was 3.10±0.49, and post-session 4.13±0.22. The average score of self-perceived skill with suction techniques in the airway scenario pre-session was 3.30±0.43, and post-session 4.03±0.26. The average score for usefulness of the session was 4.68±0.15, and the score for realism of the simulator was 4.65±0.17. CONCLUSION: A training session with the SALAD simulator improved trainee's confidence in managing the airway of a vomiting or hemorrhaging patient. The SALAD simulation system recreates the dynamic challenges associated with emergency airways and holds promise as an airway training tool.

Mechanical ventilation and resuscitation under water: Exploring one of the last undiscovered environments--A pilot study.

INTRODUCTION: Airway management, mechanical ventilation and resuscitation can be performed almost everywhere--even in space--but not under water. The present study assessed the technical feasibility of resuscitation under water in a manikin model. METHODS: Tracheal intubation was assessed in a hyperbaric chamber filled with water at 20 m of depth using the Pentax AWS S100 video laryngoscope, the Fastrach™ intubating laryngeal mask and the Clarus optical stylet with guidance by a laryngeal mask airway (LMA) and without guidance. A closed suction system was used to remove water from the airways. A test lung was ventilated to a maximum depth of 50 m with a modified Oxylator(®) EMX resuscitator with its expiratory port connected either to a demand valve or a diving regulator. Automated chest compressions were performed to a maximum depth of 50 m using the air-driven LUCAS™ 1. RESULTS: The mean cumulative time span for airway management until the activation of the ventilator was 36 s for the Fastrach™, 57 s for the Pentax AWS S100, 53s for the LMA-guided stylet and 43 s for the stylet without LMA guidance. Complete suctioning of the water from the airways was not possible with the suction system used. The Oxylator(®) connected to the demand valve ventilated at 50 m depth with a mean ventilation rate of 6.5 min(-1) vs. 14.7 min(-1) and minute volume of 4.5 l min(-1) vs. 7.6 l min(-1) compared to the surface. The rate of chest compression at 50 m was 228 min(-1) vs. 106 min(-1) compared to surface. The depth of compressions decreased with increasing depth. CONCLUSION: Airway management under water appears to be feasible in this manikin model. The suction system requires further modification. Mechanical ventilation at depth is possible but modifications of the Oxylator(®) are required to stabilize ventilation rate and administered minute volumes. The LUCAS™ 1 cannot be recommended at major depth.

Helicopter-based in-water resuscitation with chest compressions: a pilot study.

BACKGROUND: Drowning is a relevant worldwide cause of severe disability and death. The delay of ventilations and chest compressions is a crucial problem in drowning victims. Hence, a novel helicopter-based ALS rescue concept with in-water ventilation and chest compressions was evaluated. METHODS: Cardio pulmonary resuscitation (CPR) and vascular access were performed in a self-inflating Heliboat platform in an indoor wave pool using the Fastrach intubating laryngeal mask, the Oxylator resuscitator, Lund University Cardiopulmonary Assist System (LUCAS) chest compression device and EZ-IO intraosseous power drill. The time requirement and physical exertion on a Visual Analogue Scale (VAS) were compared between a procedure without waves and with moderate swell. RESULTS: Measurement of the elapsed time of the various stages of the procedure did not reveal significant differences between calm water and swell: Ventilation was initiated after 02:48 versus 03:02 and chest compression after 04:20 versus 04:18 min; the intraosseous cannulisation was completed after 05:59 versus 06:30 min after a simulated jump off the helicopter. The attachment of the LUCAS to the mannequin and the intraosseous cannulisation was rated significantly more demanding on the VAS during swell conditions. CONCLUSIONS: CPR appears to be possible when performed in a rescue platform with special equipment. The novel helicopter-based strategy appears to enable the rescuers to initiate CPR in an appropriate length of time and with an acceptable amount of physical exertion for the divers. The time for the helicopter to reach the patient will have to be very short to minimise neurological damage in the drowning victim.

Development of a rapid, safe, fiber-optic guided, single-incision cricothyrotomy using a large ovine model: a pilot study.

STUDY AIM: We present a pilot study in which we use an ovine model to develop a rapid, safe cricothyrotomy technique using a Melker cuffed 5.0 cricothyrotomy catheter loaded over a fiberoptic stainless steel optical stylet. The technique requires a single incision. The stylet allows easy placement and facilitates visual, tactile, and transillumination confirmation of intratracheal placement. We recorded this process on video to facilitate the development of the procedure and to allow others to replicate it for further research or refinement. All devices used in this technique are currently employed in clinical practice. METHODS: We performed the procedure in four anesthetized sheep, varying the technique to maximize speed, demonstrate pitfalls, and optimize video recording of confirmation methods. We recorded each case using a 4-channel digital video recorder. RESULTS: After making a single scalpel incision we inserted the stylet and confirmed placement by visualization, transillumination, "click" palpation, and gentle stylet-driven tracheal displacement. We passed the cricothyrotomy tubes without difficulty and easily ventilated the animals. CONCLUSION: The procedure is rapid, incorporates redundant safety features, and uses equipment increasingly available to anesthesiologists, emergency physicians, intensivists and surgeons. The promising outcome of this pilot study should be verified in a larger controlled, comparative trial.