Airway Corner: First Pass Success

thanks Darren and John!
I agree if you are going to use VL technique as part of your first pass success strategy then it should be incorporated in regular clinical practice. the only way to get good at VL is to do it all the time.
I content though that first pass DL optimised is as good if not better than first pass VL. When you have experienced operators the difference is marginal if any. learners or low experience intubators I accept get better views with VL on first pass, all else being equal. However that does not always translate to first pass success.

http://link.springer.com/article/10.1007%2Fs12630-012-9775-8

Purpose
Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers.
Methods
Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures.
Results
Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO2 (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO2 of 95% in the DL group [IQR 85-99] (P = 0.04).
Conclusions
Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.

Enough about video laryngoscopes already. Can we just all agree that they are really good.....and that DL also works a lot and we are really good at it and we should keep practicing and teaching both ways.

Last few months have been a bit heavy on this debate.

Since Hypoxia was considered a negative outcome....What is the outcome data on patients with a brief period of hypoxia versus no hypoxemia.

In reference to the Bounceback case....we know from good literature and past EMRAP episodes that there is ZERO utility of doing provocative testing in low risk patients with normal ECGs and normal markers. So why does Dr. Mattu keep insisting on following "guidelines" and getting outpatient testing? Is this because Americans are scaredy cats? The Guidelines have been wrong on this issue for decades now. The fact that a very rare patient actually has real disease is NOT the reason to practice defensively in my Canadian opinion.

I really enjoyed the C3 project. Any idea when that will be back?

While I agree that we should downplay the need to give antibiotics for pharyngitis, please don't downplay the risk of draining a peritonsillar abscess as no "big deal." Hello Big Red?

Aberrant internal carotid artery in the mouth mimicking peritonsillar abscess.

Lo CC, Luo CM, Fang TJ. Am J Emerg Med. 2010 Feb;28(2):259.e5-6. doi: 10.1016/j.ajem.2009.06.024.

A study of the course of the internal carotid artery in the parapharyngeal space and its clinical importance. Ozgur Z, Celik S, Govsa F, Aktug H, Ozgur T. Eur Arch Otorhinolaryngol. 2007 Dec;264(12):1483-9. Epub 2007 Jul 19.

I have drained at least 30 peritonsillar abcesses in my long career and have never hit "big red". Beware but do not be afraid. It is the right thing to do and you do not have to procrastinate with a CT scan of the neck to do it.

So, Mel, I've been an EM:RAP subscriber for over 5 yrs and look forward to each issue. Despite all of the burning questions your production has addressed, I am still left without a critical piece of data. Please settle the debate. Is the Geico Gecko an Aussie or a New Zealander?

I agree definitely not Aussie or Kiwi....English, possibly South African....

Had a great intubation the other day using principles from this lecture and others, Thanks Mel, Scott and Peter.....remember Mel what you do matters and what you do do really smells....peace out!

Your discussion regarding rheumatic fever/heart disease may be appropriate for the US, but I've seen numerous cases while working in your home country...below is some data from the Australian Institute of Health and Welfare:

Prevalence - number of Australians with condition in 2006: 1402
Incidence - new cases in 2002-06: 350
Hospitalizations in 2006-07: 2561
Deaths in 2006: 285

When your feedback includes "All of the above, it would be nice to include all of the above in the feedback. Actually it would be better to always include the whole question in the feedback.

I want C3 and hippo, bring C3 back!