Rigid fibrescope Bonfils: use in simulated difficult airway by novices.

BACKGROUND: The Bonfils intubation fibrescope is a promising alternative device for securing the airway. We examined the success rate of intubation and the ease of use in standardized simulated difficult airway scenarios by physicians. We compared the Bonfils to a classical laryngoscope with Macintosh blade. METHODS: 30 physicians untrained in the use of rigid fibrescopes but experienced in airway management performed endotracheal intubation in an airway manikin (SimMan, Laerdal, Kent, UK) with three different airway conditions. We evaluated the success rate using the Bonfils (Karl Storz, Tuttlingen, Germany) or the Macintosh laryngoscope, the time needed for securing the airway, and subjective rating of both techniques. RESULTS: In normal airway all intubations were successful using laryngoscope (100%) vs. 82% using the Bonfils (p < 0.05). In the scenario "tongue oedema" success rate using the Macintosh laryngoscope was 67% and 83% using the Bonfils. In the scenario "decreased cervical range of motion with jaw trismus", success rate using the Macintosh laryngoscope was 84% vs. 76%. In difficult airway scenarios time until airway was secured did not differ between the two devices. Use of Bonfils was rated "easier" in both difficult airway scenarios. CONCLUSION: The Bonfils can be successfully used by physicians unfamiliar with this technique in an airway manikin. The airway could be secured with at least the same success rate as using a Macintosh laryngoscope in difficult airway scenarios. Use of the Bonfils did not delay intubation in the presence of a difficult airway. These results indicate that intensive special training is advised to use the Bonfils effectively in airway management.

Comparison of two different techniques of fibreoptic intubation.

BACKGROUND AND OBJECTIVE: The application of analgesics and sedatives during fibreoptic intubation (FOI) may result in a transient decrease in arterial oxygen saturation.This study evaluates two different techniques of FOI and respective effects on procedural duration, arterial oxygen saturation, and coughing by the patient. METHODS: Thirty-four patients received a standardized conscious sedation with fentanyl (1.5 microg kg(-1)) and midazolam (12.5 microg kg(-1)).All patients were randomly allocated to one of the following techniques: the 'vaporization' (VAP) technique included four applications of 2 ml lidocaine 2% administered through the working channel of the fibrescope supplying an oxygen flow of 3 l min(-1); the 'standard' (STAN) technique included the insufflation of 3 l(-1) min oxygen via a nasal probe and two applications of 4 ml of lidocaine 2%, each followed by a maximum of 2 min to take effect. RESULTS: FOI was successful in all patients (STAN 15; 'vaporization' 17 patients). The overall intubation time interval was significantly (P < 0.001) shorter in the VAP group. There was no difference in oxygen saturation between the two groups prior to the start of FOI, but a significant (P = 0.008) decrease in oxygen saturation levels was detected in the STAN group after completion of FOI. Patients in the VAP group coughed less; a significant difference in the number of coughs (P = 0.036) was found during the application of lidocaine into the proximal trachea. CONCLUSION: The VAP technique decreases overall intubation time, increases the oxygen saturation of the patient until completion of the intubation, and reduces cough.

The EasyTube for airway management in emergencies.

BACKGROUND: The EasyTube (EzT) is a new sterile, disposable airway device approved by the European Union in February 2003 and by the U.S. Food and Drug Administration in January 2005. The two-lumen design of the EzT enables it to be used as an endotracheal tube or as a supraglottic emergency airway. OBJECTIVE: To report the preliminary experiences with the EzT airway device in prehospital and in-hospital emergency airway management procedures. METHODS: All airway management procedures involving the EzT were recorded for a period of 18 months. RESULTS: The EzT was successfully used to intubate 15 patients with unanticipated airway difficulties during either anesthesia induction or prehospital airway management. In all patients, the EzT was positioned successfully in the first attempt, within a median time of 31 seconds until start of ventilation. Effective supraglottic ventilation and oxygenation was achieved within 25 to 40 seconds. In three patients, the EzT needed one additional repositioning maneuver. On removal of the EzT, no blood was observed on the surface of the device, as a sign of absence of potential mucosal lesion. No injuries were observed in the mouth, pharynx, or esophagus. CONCLUSIONS: The first experiences with the use of the EzT are promising. In emergency airway management procedures presenting problems, the device successfully established sufficient ventilation and oxygenation. Further studies are needed to compare its value with those of other supraglottic devices.

Infraglottic airway devices and techniques.

Airway management involves far more than just proficiency with tracheal intubation techniques. There are several infraglottic techniques available and the method chosen will depend on the accessibility of equipment, the level of training and expertise, and the patient's specific injury or disease. Endotracheal intubation is most commonly performed by direct laryngoscopy. Several modifications of laryngoscope blades and a variety of adjuncts such as bougies may help to accomplish even a difficult airway. Rigid intubation fibrescopes do improve the view of the larynx, especially in patients with difficult anatomy. They also permit tracheal intubation with less head and cervical spine movement than is often generated by direct laryngoscopy. Successful intubation, however, requires considerable experience, as in intubation techniques using flexible fibrescopes. Both the EasyTube and the Combitube serve as an infraglottic or a supraglottic airway. The tip of the EasyTube resembles the one of an endotracheal tube, whereas the Combitube is much more bulky.

Bystander trauma care--effect of the level of training.

BACKGROUND: The bystander is often the first person present at the scene of an accident. Our aim was to determine how often and how well bystanders perform trauma care and whether trauma care is affected by the bystander's level of training, relationship to the patient and numbers of bystanders present. PATIENTS AND METHODS: In a prospective 1-year study, the emergency medical service in two European cities collected data on trauma calls. Questionnaires were used to document the bystanders' level of training (none, basic, advanced, professional), the bystander's relationship to the patient, and the number of bystanders present, and to assess whether five separate measures of trauma care (ensuring scene safety, extrication of the patient, positioning, control of haemorrhage, prevention of hypothermia) were performed correctly, incorrectly, or not at all. RESULTS: Two thousand nine hundred and thirty-two trauma calls were documented and bystanders were present in 1720 (58.7%). All measures except ensuring scene safety and prevention of hypothermia were affected by the bystander's level of training. Correct extrication, positioning, and control of haemorrhage increased with the level of bystander training while the number of patients who were not attended decreased (P < 0.05, P < 0.005, P < 0.005), respectively. The relationship to the patient did not affect whether, or how well, any measure was performed. The number of bystanders present only affected prevention of hypothermia, which was performed most often when only one bystander was present. CONCLUSION: Improved, more widespread training could increase the frequency and quality of bystander trauma care further.

Medical support for children's mass gatherings.

INTRODUCTION: Medical care must be well-planned for mass gatherings. Events such as fairs, concerts, parades, and rallies cause many people to gather in one place, increasing the chance of injuries and for the development of a disaster. In this study, the level and quality of medical care were evaluated at a mass gathering of approximately 100,000 children. The event was a television-sponsored fun fair. METHODS: Every patient contact was documented on printed forms, including data such as the number of patients treated, gender of the patients, presence or absence of a parental escort, time distribution of patient contacts, the diagnoses for the patient contacts, specific therapies applied, duration of the treatment, and patient discharge information. All data were coded after the event and transferred into a computer database. These data were analyzed using descriptive statistics. RESULTS: Of the 100,000 spectators, 192 patients (81 male [42.2%] and 111 female [57.8%]) were treated during the nine-hour period, from 09:00 hours (h) until 18:00 h. Twenty percent of all the children up to the age of 10 years needing medical assistance were not accompanied by an adult. Seventy-five percent of all patient contacts were made during the afternoon. Of those treated, 164 patients (85.4%) suffered only minor injuries and were seen for <10 minutes. The most common type of complaint was minor trauma (103 patients, 53.6%); followed by minor medical problems such as headaches or light allergic reactions (21 patients, 10.9%); insect bites (20 patients, 10.4%); and serious medical problems or trauma such as severe arterial hypertension or long bone fractures (19 patients, 9.9%). Treatment included, but was not limited to, dressings (100 patients; 52.1%), local therapy (68 patient, 35.4%), and analgesic therapy (10 patients, 5.2%). Four patients (2%) were transferred to local hospitals. CONCLUSION: Most of the medical needs in the patients attending the children's fun fair were minor. Nevertheless, for similar events in the future, the medical team should be qualified for all serious medical emergencies, as well as major trauma; and should be prepared to meet the requirements of the specific group of spectators. The overall usage rate in the children's fun fair described was 19.2 patient encounters per 10,000 spectators. Half of all of the patients were children below the age of 14 years. Medical services should consider that this study shows that up to 33% of children seeking medical assistance may not be accompanied by adults.

Near-hanging.

Each year, thousands of people are strangled. Survival from strangulation or hanging is often associated with various complications including a large variety of neurological consequences. As it is common knowledge that the GCS and other initial presenting findings bear a poor correlation to the ultimate outcome, aggressive resuscitation and treatment of post anoxic brain injury is indicated in every patient in absence of definite signs of death and irrespective of the duration of hypoxia or unconsciousness in cases of strangulation, especially in cases of suicidal near-hanging. These case reports describe two near-hanging episodes in patients with a normal neurological outcome.