1. Do you reach for video laryngoscopy or direct laryngoscopy first for intubations?
2. Do you use cricoid pressure during induction and paralysis?
3. How long do you keep patients NPO prior to procedural sedation?
4. When using ketamine for procedural sedation do you pretreat with benzodiazepines or anticholinergics?
EM Lyceum 
1. Video 2. Sometimes 3. At least 1 hour 4. No
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1. Video 2. Never 3. Zero 4. Neither
1: DL 2: No 3: 0h 4: No
1) I alternate; 2) No (but use laryngeal manipulation to enhance view of cords 3) n/a for most (emergent) cases 4) NO!
1. I opt for DL first but always have VL ready. I have read multiple studies that show evidence for VL as superior but not all of them are done on patients in the ED. See 5 article below for further reading. These are ED patients only and I excluded any company sponsored trial. In my opinion the bugie with DL is the best combination for difficult airway.
1. Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations.
Sakles JC1, Mosier JM, Chiu S, Keim SM.
Author information
Abstract
BACKGROUND:
Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy.
OBJECTIVES:
To compare the success rates of GlideScope(®) (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations.
METHODS:
This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope(®) standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure.
RESULTS:
There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005.
CONCLUSION:
The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management.
Published by Elsevier Inc.
PMID: 21689899 [PubMed – indexed for MEDLINE]
2. Acad Emerg Med. 2009 Sep;16(9):866-71. doi: 10.1111/j.1553-2712.2009.00492.x. Epub 2009 Aug 6.
A comparison of GlideScope video laryngoscopy versus direct laryngoscopy intubation in the emergency department.
Platts-Mills TF1, Campagne D, Chinnock B, Snowden B, Glickman LT, Hendey GW.
Author information
Abstract
OBJECTIVES:
The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED).
METHODS:
A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts.
RESULTS:
A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p < 0.01).
CONCLUSIONS:
Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.
(c) 2009 by the Society for Academic Emergency Medicine.
Comment in
The ethics of observation. [Acad Emerg Med. 2009]
3. Comparison of GlideScope Videolaryngoscopy to Direct Laryngoscopy for Intubation of a Pediatric Simulator by Novice Physicians
Joni E. Rabiner,1 Marc Auerbach,2 Jeffrey R. Avner,1 Dina Daswani,1 and Hnin Khine1
Emergency Medicine International
Volume 2013 (2013), Article ID 407547, 6 pages
Abstract
Objective. To compare novice clinicians’ performance using GlideScope videolaryngoscopy (GVL) to direct laryngoscopy (DL). Methods. This was a prospective, randomized crossover study. Incoming pediatric interns intubated pediatric simulators in four normal and difficult airway scenarios with GVL and DL. Primary outcomes included time to intubation and rate of successful intubation. Interns rated their satisfaction of the devices and chose the preferred device. Results. Twenty-five interns were included. In the normal airway scenario, there were no differences in mean time for intubation with GVL or DL (61.4 versus 67.4 seconds, ) or number of successful intubations (19 versus 18, ). In the difficult airway scenario, interns took longer to intubate with GVL than DL (87.7 versus 61.3 seconds, ), but there were no differences in successful intubations (14 versus 15, ). There was a trend towards higher satisfaction for GVL than DL (7.3 versus 6.4, ), and GVL was chosen as the preferred device by a majority of interns (17/25, 68%). Conclusions. For novice clinicians, GVL does not improve time to intubation or intubation success rates in a pediatric simulator model of normal and difficult airway scenarios. Still, these novice clinicians overall preferred GVL.
4. Comparison of video and direct laryngoscope for tracheal intubation in emergency settings: A meta-analysis
Yi-Kung Lee, Chien-Chih Chen, Tzong-Luen Wang, Kueiyu Joshua Lin, Yung-Cheng Sucorrespondenceemail
Received: March 13, 2012; Accepted: April 25, 2012; Published Online: June 29, 2012
Abstract
Background
Video laryngoscope has recently been introduced as an alternative for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. Therefore, we conducted a meta-analysis to assess its value compared with direct laryngoscope in emergency settings.
Purpose
We conducted a meta-analysis to assess its value compared with direct laryngoscope in emergency settings.
Methods
PubMed and EMBASE were searched for studies published through April 2011. Trials that reported data comparing video laryngoscope versus direct laryngoscope-assisted intubation in the emergency room or prehospital locations were included.
Results
Four trials reporting a total of 1305 participants were identified. During intubation, video laryngoscope failed to produce high rates of successful intubation (success rate: 0.70; 95% confidence interval [CI]: 0.49–1.01). Time to intubation was not different when using either video laryngoscope or direct laryngoscope (standardized mean difference: 0.19; 95% CI: -0.20—0.58). Furthermore, video laryngoscope seems to achieve a similar glottic view as direct laryngoscope (ratio of better glottic view: 0.96; 95% CI: 0.63–1.46).
Conclusion
In the reviewed studies, video laryngoscope was not superior to direct laryngoscope for performing intubation in emergency settings.
5.Learning Curves for Direct Laryngoscopy and GlideScope® Video Laryngoscopy in an Emergency Medicine Residency
Journal Issue:
Western Journal of Emergency Medicine, 15(7)
Author:
Sakles, John C., University of Arizona, Department of Emergency Medicine, Tucson, Arizona;
Mosier, Jarrod M., University of Arizona, Department of Emergency Medicine, Tucson, Arizona;
Patanwala, Asad E., University of Arizona College of Pharmacy, Department of Pharmacy Practice and Science, Tucson, Arizona;
Dicken, John M., University of Arizona College of Medicine, Tucson, Arizona
Introduction: Our objective is to evaluate the resident learning curves for direct laryngoscopy (DL) and GlideScope® video laryngoscopy (GVL) over the course of an emergency medicine (EM) residency training program.
Methods: This was an analysis of intubations performed in the emergency department (ED) by EM residents over a seven-year period from July 1, 2007 to June 30, 2014 at an academic ED with 70,000 annual visits. After EM residents perform an intubation in the ED they complete a continuous quality improvement (CQI) form. Data collected includes patient demographics, operator post- graduate year (PGY), difficult airway characteristics (DACs), method of intubation, device used for intubation and outcome of each attempt. We included in this analysis only adult intubations performed by EM residents using a DL or a standard reusable GVL. The primary outcome was first pass success, defined as a successful intubation with a single laryngoscope insertion. First pass success was evaluated for each PGY of training for DL and GVL. Logistic mixed-effects models were constructed for each device to determine the effect of PGY level on first pass success, after adjusting for important confounders.
Results: Over the seven-year period, the DL was used as the initial device on 1,035 patients and the GVL was used as the initial device on 578 patients by EM residents. When using the DL the first past success of PGY-1 residents was 69.9% (160/229; 95% CI 63.5%-75.7%), of PGY-2 residents was 71.7% (274/382; 95% CI 66.9%-76.2%), and of PGY-3 residents was 72.9% (309/424; 95% CI 68.4%-77.1%). When using the GVL the first pass success of PGY-1 residents was 74.4% (87/117; 95% CI 65.5%-82.0%), of PGY-2 residents was 83.6% (194/232; 95% CI 76.7%-87.7%), and of PGY-3 residents was 90.0% (206/229; 95% CI 85.3%-93.5%). In the mixed-effects model for DL, first pass success for PGY-2 and PGY-3 residents did not improve compared to PGY-1 residents (PGY-2 aOR 1.3, 95% CI 0.9-1.9; p-value 0.236) (PGY-3 aOR 1.5, 95% CI 1.0-2.2, p-value 0.067). However, in the model for GVL, first pass success for PGY-2 and PGY-3 residents improved compared to PGY-1 residents (PGY-2 aOR 2.1, 95% CI 1.1-3.8, p-value 0.021) (PGY-3 aOR 4.1, 95% CI 2.1-8.0, p8 hours) on emesis and aspiration during
ED procedural sedation. None of these studies demonstrated a
significant difference in rates of emesis or aspiration when
comparing fasting times. In addition, no serious adverse events
caused by emesis or aspiration were found. The current evidence
does not support the rationale put forth in the non–emergency
medicine guidelines that adhering to a minimum fasting time
reduces adverse events in ED procedural sedation.
Roback et al26 performed a single-center study of 1,555
pediatric patients undergoing procedural sedation with ketamine,
midazolam, midazolam/ketamine, midazolam/fentanyl, and a
small number of other agents. The study found no relationship
between fasting time and the proportion of patients with adverse
events. Respiratory adverse events were defined as apnea,
laryngospasm, pulse oximetry less than 90% on room air at the
elevation of the study site (5,280 feet), and aspiration. Any
adverse events (vomiting or adverse respiratory event) occurred in
12.0% in the 0- to 2-hour group, 16.4% in the 2- to 4-hour
4. I DO NOT pretreat with benzodiazepines or anticholinergics when using ketamine. See below from ACEPs 2011 Clinical Practice Guidelines.
Coadministered Anticholinergics
Traditionally the prophylactic coadministration of an
anticholinergic (ie, atropine or glycopyrrolate) has been routinely
recommended, with the intent of mitigating oral secretions and
thus presumably airway adverse events.1,12,15,16 However, large
case series of patients have been safely treated without this
adjunct.35,80 The large meta-analysis found anticholinergics to
be associated with significantly more airway and respiratory
adverse events and significantly less vomiting; however, both
were at magnitudes of doubtful clinical importance.2,3,81 Given
this lack of tangible benefit or harm, the literature is not
supportive of anticholinergic prophylaxis. Instead, these drugs
could be reserved for the treatment of unusual occurrences of
clinically important hypersalivation or for patients with an
impaired ability to mobilize secretions.
Coadministered Benzodiazepines
As with anticholinergics, the prophylactic coadministration of
benzodiazepines has been traditionally recommended with the
intent of preventing or reducing recovery reactions.4,12,15,16 A
single controlled trial in ED adults found that midazolam
pretreatment (0.03 mg/kg IV) significantly reduced the
incidence of recovery agitation by 17% (number needed to
benefit6).28 Unfortunately, this study failed to describe the
nature or severity of these reactions, and so it remains unclear
how many of the events were clinically important and how
many were minor and transient. Nevertheless, midazolam
prophylaxis appears a reasonable but nonmandatory option in
adults.
In children, however, 2 controlled trials82,83 and a large
meta-analysis3 have failed to note even a trend toward benefit
from such prophylaxis. Children have far fewer recovery
reactions than adults, and thus the routine pretreatment of such
patients is not supported by the evidence.
When unpleasant ketamine-associated recovery reactions do
rarely occur, they can be rapidly and reliably diminished with
titrated benzodiazepines.4,12,16,19,20,36,71,83,84
2. I do not routinely use cricoid pressure. I do not find that it helps with my view and have not been convinced about its benefit based on research I have read.Coppy and paste the link below in your browser for a nice review.
file:///C:/Users/discharge/Downloads/annals-of-emergency-medicine-2007-ellis1.pdf
3. In the ER I have no control over when a patient last took PO and DO NOT let it affect my decision on procedural sedation. See below from ACEPs 2014 Clinical Policies.
CRITICAL QUESTIONS
1. In patients undergoing procedural sedation and
analgesia in the emergency department, does preprocedural
fasting demonstrate a reduction in the risk of emesis or
aspiration?
Recommendations
Level A recommendations. None specified.
Level B recommendations. Do not delay procedural sedation
in adults or pediatrics in the ED based on fasting time.
Preprocedural fasting for any duration has not demonstrated a
reduction in the risk of emesis or aspiration when administering
procedural sedation and analgesia.
Level C recommendations. None specified.
Key words/phrases for literature searches: conscious sedation,
sedation, procedural sedation, procedural analgesia, moderate
sedation, deep sedation, fasting, gastric emptying, complication,
aspiration, emesis, and variations and combinations of the key
words/phrases; years January 2004 to May 2012.
Emesis or aspiration during procedural sedation in the ED
is rare.21 For healthy patients undergoing elective sedation/
analgesia, other professional society guidelines outside of
emergency medicine recommend a 2-hour fasting time for
clear liquids, 4-hour fasting time for breast milk, and a 6-hour
fasting time for solids. However, the guidelines are based on the
extrapolation of general anesthesia cases in the operating room,
in which airway manipulation during intubation and extubation
increases the aspiration risk. Thus, it is not clear whether
applying these guidelines to ED procedural sedation and
analgesia reduces the risk of emesis or aspiration. Moreover, even
within the framework of these guidelines, emergent sedations
are an exclusion from fasting requirements.22
As a result, guidelines for elective procedures in the operating
room (eg, nothing by mouth, preoperative fasting guidelines) are
not directly applicable in the ED. In addition, multiple other
practice guidelines and systematic reviews do not find evidence to
support a specific fasting period before ED procedural sedation.
Two systematic reviews23,24 and 2 practice advisories11,25
acknowledge the lack of evidence to support specific preprocedural
fasting requirements.
Four Class II trials with pediatric patients26-29 and 1 Class II
trial with adult and pediatric patients30 examined the effect
of fasting time (0 to >8 hours) on emesis and aspiration during
ED procedural sedation. None of these studies demonstrated a
significant difference in rates of emesis or aspiration when
comparing fasting times. In addition, no serious adverse events
caused by emesis or aspiration were found. The current evidence
does not support the rationale put forth in the non–emergency
medicine guidelines that adhering to a minimum fasting time
reduces adverse events in ED procedural sedation.
Roback et al26 performed a single-center study of 1,555
pediatric patients undergoing procedural sedation with ketamine,
midazolam, midazolam/ketamine, midazolam/fentanyl, and a
small number of other agents. The study found no relationship
between fasting time and the proportion of patients with adverse
events. Respiratory adverse events were defined as apnea,
laryngospasm, pulse oximetry less than 90% on room air at the
elevation of the study site (5,280 feet), and aspiration. Any
adverse events (vomiting or adverse respiratory event) occurred in
12.0% in the 0- to 2-hour group, 16.4% in the 2- to 4-hour group, 14.0% in the 4- to 6-hour group, 14.6% in the 6- to
8-hour group, and 14.5% in the greater than 8 hours group.
Using the group that fasted 0 to 2 hours as the reference group,
the difference in proportion of any adverse events was 4.3% in
the 2- to 4-hour group, 2.0% in the 4- to 6-hour group, 2.6% in
the 6- to 8-hour group, and 2.5% in the greater than 8 hours
group. There were no aspiration events documented in the entire
cohort of 1,555 patients.
Treston27 included 257 pediatric patients undergoing
procedural sedation with ketamine. In this study also, fasting
time did not correlate with the incidence of emesis, which
occurred in 6.6% in the 1 hour or less fasting group, 14.0% in
the 1- to 2-hour fasting group, and 15.7% in the 3 hours or
greater group. Using the group that fasted 1 hour or less as the
reference group, the difference in proportion of vomiting in the
1- to 2-hour fasting group was 7.3%; in the 3-hour or greater
group, 9.1%. No clinically detectable aspiration occurred, and no
airway maneuvers or suctioning was required.
Babl et al28conducted a study of 218 consecutive pediatric
patients undergoing procedural sedation with nitrous oxide.
Fasting guidelines for solids were not met by 71.1% of the patients.
There was no statistical difference in incidence of emesis, which
occurred in 7.1% of patients who did not meet fasting guidelines
for solids compared with 6.3% in those who met guidelines.
Serious adverse events were defined as pulse oximetry less than
95%, apnea, stridor, airway misalignment requiring repositioning,
laryngospasm, bronchospasm, cardiovascular instability,
pulmonary aspiration, unplanned hospital admission,
endotracheal intubation, permanent neurologic injury, or death.
There were no serious adverse events observed.
McKee et al29 examined 471 pediatric patients undergoing
procedural sedation with ketamine, in which presedation oral
analgesic administration was recorded. In this Class II study,
42.7% of patients received oral analgesics within 6 hours of
sedation. Emesis occurred in 5.0% of patients who received oral
analgesics compared with 2.6% of patients who did not receive
oral analgesics. Additional adverse events recorded were hypoxia
(desaturation requiring supplemental oxygen), hypoventilation,
laryngospasm, apnea, bradycardia, or tachycardia. Total adverse
events were similar for patients receiving oral analgesia (5.0%)
and those not receiving oral analgesia (5.6%). The authors did
not report episodes of intubation, aspiration, unplanned
admission, or death, although these were not explicit outcome
measures in the study.
Bell et al30 followed 400 adult and pediatric patients
undergoing procedural sedation with propofol. The authors
found that 70.5% of those enrolled did not meet American
Society of Anesthesiologists (ASA) fasting guidelines for solids or
liquids. They identified no significant difference between the
groups meeting and not meeting fasting guidelines with respect
to adverse events that included emesis and respiratory
interventions. Emesis occurred in 0.4% of patients who did not
meet fasting guidelines compared with 0.8% of those who met
guidelines. The combined endpoint of respiratory adverse events
was defined as transient apnea, pulse oximetry less than 95%,
respiratory rate less than 12 breaths/min, elevated end-tidal
carbon dioxide (ETCO2) greater than 10 mm Hg, vomiting, and
aspiration. Respiratory adverse events occurred in 22.4% of
patients who did not meet fasting guidelines compared with
19.5% of those who met guidelines. With only 2 episodes of
emesis and no aspiration events, this combined endpoint was
driven primarily by interventions less likely to be related to
fasting, such as respiratory depression and desaturation. The
combined endpoint of respiratory interventions was defined as
basic airway maneuvers, Guedel/bag-valve-mask, and suctioning.
Respiratory interventions occurred in 33.3% of patients who did
not meet fasting guidelines compared with 24.6% of those who
met guidelines. With only 3 interventions requiring suctioning,
this combined endpoint is predominantly weighted by basic
airway and bag-valve-mask interventions, which are less likely to
be affected by fasting. There were no aspiration events,
intubations, laryngeal mask airway insertions, or unplanned
admissions related to sedation or recovery in either group.
Future research should focus on the identification of a
potential high-risk population that might benefit from a fasting
time or a sedation agent with better efficacy after patient fasting if
such a delay is to be relevant in any ED procedural sedations. In
addition, research into the harms of enforcing fasting periods
would bring balance to the literature. Concerns about procedural
difficulty, ED resource utilization, and pediatric hypoglycemia
related to enforced fasting periods for ED procedural sedation
have not been evaluated.
1. I go for DL first unless PT can cooperate and I know their Mallampatti is 3-4 or their LEMON is poor, then VL first. Then VL is for a second attempt after DL if I get a very low or 0/100 POGO score or first DL attempt w/ bougie is unsuccessful. 2. No cricoid pressure. 3. I work prehospital so no luxury of NPO. 4. I do not pretreat before I give ketamine, but I do resuscitate first if possible then follow with Midazolam boluses appropriately after. No anticholinergics either.
1. Lately…video
2. No
3. Zero mins
4. Never