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Critical Care Mailbag – The Crash RSI Checklist

Anand Swaminathan, MD FAAEM and Scott Weingart, MD
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13:27
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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02:39

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EMRAP_2018_09_September_Written Summary 440 KB - PDF

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Paul B., M.D. -

Great piece on an important topic.

Positioning the patient is key but so is the position for the airway manager and the devices used.

We have taught a ground-level intubations as part of a Tactical Airway Station at our residency program, shout out to www.statenislandem.com! This incorporates field airway management techniques for our trainees who may be faced with this non-traditional airway in an emergency (medical response team, EMS or wilderness experience, etc.)

A couple of points that I think should be added: the literature supports video laryngoscopy as superior to direct for ground level intubation. Blade lighting may be an issue as well so check your equipment if possible.

If video is unavailable, the left lateral recumbent position has also been shown to reduce the incidence of a difficult laryngoscopy. Try it! We did. It's actually much easier to have your body out of the way to use your non-laryngoscoping hand for tube delivery.

That being said, I think the tube-over-thebougie is the method of choice for an a priori "crash airway". By the time you're moving to bougie, if only as a "rescue" you may have missed your only chance to secure that airway. Seldinger'ed bougie technique would be my first option.

The widespread use of end-tidal capnography to determine tube placement was first demonstrated in the prehospital literature by Silvestri et al. 2004. ED use mostly came online after EMS was doing it in the field.

An issue with supraglottic airway placement in the EMS setting for a semi-consicous patient is that most of these devices were not approved for such a use by the FDA. Regional legislative medical oversight bodies may have difficulties approving devices for uses against their original intent despite the possible utility to the patient. Unfortunately the litigious nature of these conditions are at the forefront of decisions surrounding optimal patient care. Regardless of what an EMS Medical Director may want to do, the local protocols can restrict some aspects of care. It is clear the SGA has a role in the peri-arrest patient and stakeholders should work together to enhance prehospital airway management techniques, not restrict them.

References:
Komatsu R et al. Airway scope and Macintosh laryngoscope for tracheal intubation in patients lying on the ground. Anesth Analg 2010;111(2):427-431.

Adnet F et al. Optimization of glottic exposure during intubation of a patient lying supine on the ground. Am J Emerg Med 1997; 15(6):555-7.

Adnet G et al. Emergency tracheal intubation of patients lying supine on the ground: influence of operator body position. Can J Anesth 199;45(3): 266-9.

Wetsch W et al. Success rates and endotracheal tube insertion times of experienced emergency physicians using five video laryngoscopes: a randomized trial in a simulated trapped car accident victim. Eur J Anesthesiol 2011;28(12):850-8.

Silvestri et al. The Effectiveness of Out Of Hospital Use of Continuous End Tidal Carbon Dioxide Monitoring on the Rate of Unrecognized Misplaced Intubation Within a Regional Emergency Medical Services System.

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EM:RAP 2018 September Full episode audio for MD edition 213:30 min - 313 MB - M4AEM:RAP 2018 September Canadian Edition Canadian 25:37 min - 35 MB - MP3EM:RAP 2018 September German Edition Deutsche 99:49 min - 137 MB - MP3EM:RAP 2018 September French Edition Français 21:59 min - 30 MB - MP3EM:RAP 2018 September Aussie Edition Australian 39:22 min - 54 MB - MP3EM:RAP 2018 September Spanish Edition Español 78:35 min - 108 MB - MP3EMRAP 2018 08 Sept Individual MP3 277 MB - ZIPEMRAP 2018 09 Sept Board Review Answers 130 KB - PDFEMRAP 2018 09 Sept Board Review Questions 238 KB - PDFEMRAP 2018 September Summary (SPA) 763 KB - PDFEMRAP 2018 09 September Individual Summaries 765 KB - ZIPEMRAP_2018_09_September_Written Summary 440 KB - PDF

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