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PubMed1998

The self-inflating bulb to detect esophageal intubation during emergency airway management.

BACKGROUND: The negative-pressure test using a self-inflating bulb (SIB) during emergency intubation was studied to determine its reliability and predictive value in this setting. METHODS: The endotracheal tube (ETT) position was tested in 300 consecutive patients undergoing in-hospital emergency endotracheal intubation. Immediately after intubation and before ETT cuff inflation, the following protocol was strictly followed: (1) an SIB was compressed, connected to the ETT, and released. A 10-s period was allowed for the bulb to inflate. (2) The ETT cuff was inflated, and the ETT position was confirmed using colorimetric or infrared carbon dioxide detection, or both, combined with clinical evaluation. RESULTS: There were 19 esophageal intubations (6% incidence). The SIB correctly identified all patients with esophageal intubation (sensitivity, 100%) and correctly identified all but three ETTs placed in the trachea (specificity, 99%). The three tracheally placed tubes that were misidentified by the bulb syringe occurred during one case each of chronic obstructive pulmonary disease, copious secretions, and obesity; of note were three tracheally placed tubes that were misidentified by the carbon dioxide analyzers during cardiopulmonary resuscitation. CONCLUSIONS: The SIB proved to be a sensitive and specific test for esophageal intubation in the emergency setting when used according to the protocol described, and it is complementary to carbon dioxide detection. The predictive value of the bulb syringe appears to be improved when a prolonged period for reinflation is allowed. It holds particular promise because of its low cost and portability.

Adult↗
PubMed1999

Additive contribution of nitrous oxide to sevoflurane minimum alveolar concentration for tracheal intubation in children.

BACKGROUND: To study the interaction between nitrous oxide and sevoflurane during trachea intubation, the authors determined the minimum alveolar concentration of sevoflurane for tracheal intubation (MAC(TI)) with and without nitrous oxide in children. METHODS: Seventy-two children aged 1-7 yr were assigned randomly to receive one of three end-tidal concentrations of nitrous oxide and one of four end-tidal concentrations of sevoflurane: 0% nitrous oxide with 2.0, 2.5, 3.0, or 3.5% sevoflurane: 33% nitrous oxide with 1.5, 2.0, 2.5, or 3.0% sevoflurane; or 66% nitrous oxide with 1.0, 1.5, 2.0, or 2.5% sevoflurane. After steady state end-tidal anesthetic concentrations were maintained for at least 10 min, laryngoscopy and intubation were attempted using a straight-blade laryngoscope and an uncuffed tracheal tube. The interaction between nitrous oxide and sevoflurane was investigated using logistic regression analysis of the responses to intubation. RESULTS: Logistic regression curves of the probability of no movement in response to intubation in the presence of sevoflurane and 0, 33, and 66% nitrous oxide were parallel. The interaction coefficient between nitrous oxide and sevoflurane did not differ significantly from zero (P = 0.89) and was removed from the logistic model. The MAC(TI) (+/- SE) of sevoflurane was 2.66+/-0.16%, and the concentration of sevoflurane required to prevent movement in 95% of children was 3.54+/-0.25%. Thirty-three percent and 66% nitrous oxide decreased the MAC(TI) of sevoflurane by 18% and 40% (P<0.001), respectively. CONCLUSIONS: We conclude that nitrous oxide and sevoflurane suppress the responses to tracheal intubation in a linear and additive fashion in children.

Age Factors↗
PubMed2000

Acoustic reflectometry profiles of endotracheal and esophageal intubation.

BACKGROUND: Acoustic reflectometry can be used to create a "one-dimensional image" of a cavity, such as the airway and lung, with the image displayed as an area-length curve. This pilot study was undertaken to determine whether acoustic reflectometry could be used to distinguish between an endotracheal and an esophageal intubation. METHODS: Ten adult patients underwent general endotracheal anesthesia and neuromuscular blockade. The reflectometer wavetube was attached to an endotracheal tube, and a reflectometric profile was obtained of the endotracheal tube and the airway and lung cavity. After confirmation of tracheal intubation, a second endotracheal tube was placed in the esophagus. After four breaths were administered, a reflectometric profile of the endotracheal tube-esophagus cavity was obtained. RESULTS: The acoustic reflectometric profiles for tracheal and esophageal intubation profiles were distinctive and characteristic. For an endotracheal tube-airway cavity, the profile shows a constant cross-sectional area throughout the length of the endotracheal tube, followed by a rapid rise in the area past the carina. For an esophageal intubation, the profile shows constant cross-sectional area throughout the length of the endotracheal tube, followed by a sudden decrease in the cross-sectional area to zero. CONCLUSIONS: In this pilot study, acoustic reflectometry within seconds, and without resort to capnography, was able to generate characteristic and distinctive area-length profiles for both endotracheal and esophageal intubation. Acoustic reflectometry may have a role in the emergency imaging of the airway, and in the immediate detection of esophageal intubations, particularly in cases of cardiopulmonary arrest in which the usual techniques for confirmation of breathing tube placement fail.

Acoustics↗
PubMed2004

Teaching residents pediatric fiberoptic intubation of the trachea: traditional fiberscope with an eyepiece versus a video-assisted technique using a fiberscope with an integrated camera.

BACKGROUND: The authors' hypothesis was that a video-assisted technique should speed resident skill acquisition for flexible fiberoptic oral tracheal intubation (FI) of pediatric patients because the attending anesthesiologist can provide targeted instruction when sharing the view of the airway as the resident attempts intubation. METHODS: Twenty Clinical Anesthesia year 2 residents, novices in pediatric FI, were randomly assigned to either the traditional group (traditional eyepiece FI) or the video group (video-assisted FI). One of two attending anesthesiologists supervised each resident during FI of 15 healthy children, aged 1-6 yr. The time from mask removal to confirmation of endotracheal tube placement by end-tidal carbon dioxide detection was recorded. Intubation attempts were limited to 3 min; up to three attempts were allowed. The primary outcome measure, time to success or failure, was compared between groups. Failure rate and number of attempts were also compared between groups. RESULTS: Three hundred patient intubations were attempted; eight failed. On average, the residents in the video group were faster, were three times more likely to successfully intubate at any given time during an attempt, and required fewer attempts per patient compared to those in the traditional group. CONCLUSIONS: The video system seems to be superior for teaching residents fiberoptic intubation in children.

Child↗
PubMed2005

Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation.

BACKGROUND: Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiberoptic orotracheal intubation is often impeded. The goal of this study was to identify the sites and mechanisms that inhibit the passing of the ETT into the trachea. METHODS: Forty-five consenting patients underwent a clinically indicated awake fiberoptic orotracheal intubation. After topical anesthesia, nerve block, or both, an awake fiberoptic orotracheal intubation was performed. The placement of the FB and advancement of the ETT over the FB were videotaped using a second nasally inserted FB. An otolaryngologist later reviewed the videotaped data. RESULTS: The right arytenoid or the interarytenoid soft tissues inhibited advancement of the ETT in 42 and 11% of all patients, respectively. In all cases in which the FB was located on the right side of the larynx, failure of ETT advancement almost always occurred at the right arytenoid. Withdrawing the ETT and rotating it 90 degrees counterclockwise resulted in successful intubation on the second, third, and fourth attempts in 26.6, 20, and 0.7% of patients, respectively. CONCLUSION: The right arytenoid frequently inhibits advancement of the ETT over the FB into the trachea during awake fiberoptic orotracheal intubation. The FB position in the larynx before tube advancement and the orientation of the ETT are relevant factors in failure of advancement of the ETT into the trachea. The authors recommend positioning the FB in the center of the larynx and orienting the bevel of the ETT to face posteriorly during the first attempt at intubation.

Arytenoid Cartilage↗
PubMed1981

Prolonged oro- or nasotracheal intubation.

From July 1975 to September 1979, 6 patients were treated with truly prolonged endotracheal intubation; the duration ranged from 55--155 days. Only patients who survived after extubation and were discharged from the hospital were included in this study. Of the 6 patients, 4 were still alive as of November 1980, 23 patients died from causes not related to the intubation. The most common complication was hoarseness, which occurred in 4 patients. During the time of the study, 3 patients who were intubated in excess of 50 days did not survive. In none of these cases was the patient's death related to the intubation. The authors believe that the risk of long-term intubation has been reduced significantly by the use of nasotracheal tubes and to the newer tube materials, which are completely biocompatible, and to improved techniques of cuff inflation. Complications to tracheostomy are less frequent, but often more serious, than complications of long-term nasotracheal intubation.

Adolescent↗
PubMed1989

Succinylcholine and atropine for premedication of the newborn infant before nasotracheal intubation: a randomized, controlled trial.

Twenty preterm newborn infants were randomized to receive either atropine alone (20 micrograms/kg) or atropine plus succinylcholine (2 mg/kg) before nasotracheal intubation. Heart rate, BP, transcutaneous PO2, and intracranial pressure were monitored continuously before, during, and after intubation. No infants developed bradycardia or hypoxia. Intracranial hypertension developed during intubation in the infants receiving atropine alone, but was prevented by premedication with succinylcholine and atropine (p less than .01). A 41% increase in systemic BP occurred immediately after the administration of succinylcholine (p less than .01). BP increased during intubation in both groups, and the overall peak BP was not significantly different between the groups. Intubation was significantly shorter in the infants receiving succinylcholine. Premedication with succinylcholine and atropine will facilitate intubation of neonates, and ameliorate the adverse physiologic consequences of this procedure.

Atropine↗
PubMed1992

Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial.

OBJECTIVE: To study the effects of pharmacologically increasing gastric pH on gastric colonization and the development of pneumonia in intubated critically ill patients. DESIGN: Randomized, controlled trial. SETTING: Medical ICU in a university hospital. PATIENTS: Thirty-four tracheotomized patients with tetanus. INTERVENTIONS: Sixteen patients received iv ranitidine to increase gastric pH greater than 4 (ranitidine group), while 18 patients received no prophylaxis for upper gastrointestinal bleeding (control group). MEASUREMENTS AND MAIN RESULTS: Mean gastric pH was higher in the ranitidine group (median 4.7, range 3.6 to 6.1) than in the control group (median 2.1, range 1.2 to 4.9; p less than .05). Gastric colonization occurred in 15 (94%) of 16 patients who received ranitidine, 2 days (median; range 1 to 5) after intubation; gastric colonization also occurred in all control patients (median 4 days, range 1 to 9; p less than .05). Pneumonia occurred in 13 (81%) of 16 patients who received ranitidine, 3 days (median, range 1 to 5) after intubation and in nine (50%) of 18 control patients (p less than .01) 5 days after tracheal intubation (median, range 3 to 14; p less than .01). Prior gastric colonization by the pathogen that caused pneumonia was demonstrable in nine (56%) of 16 patients who received ranitidine vs. eight (44%) of 18 control patients (p greater than .05). The risk for developing pneumonia in the ranitidine-treated group was highest in the first 4 days after tracheal intubation. There was no difference in the frequency of upper gastrointestinal hemorrhage in the two groups. CONCLUSIONS: Pharmacologically increasing gastric pH increases the risk for developing pneumonia in intubated critically ill patients. The pneumonia occurs earlier than in untreated control patients.

Adolescent↗
PubMed1993

Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial.

OBJECTIVE: To compare the occurrence rate of nosocomial maxillary sinusitis and pneumonia in patients who have undergone nasotracheal vs. orotracheal intubation. DESIGN: Randomized, clinical trial. SETTING: General adult intensive care unit (ICU) in a nonteaching public hospital. PATIENTS: A total of 300 (209 male, 91 female) patients were included. The mean age was 59 +/- 17 (SD) yrs. The simplified acute physiologic score was 14 +/- 6. Reasons for admission to the ICU were: coma (n = 78), pneumonia (n = 46), infection (n = 35), surgery (n = 34), multiple trauma (n = 20), head trauma (n = 12), other (n = 75). Among the 300 patients, 149 were randomized into the nasotracheal group and 151 into the orotracheal group. No statistical difference was found between initial characteristics of the two groups. INTERVENTIONS: Patients were randomized between nasal and oral endotracheal intubation. Gastric intubation was performed via the same route as endotracheal intubation. Sinus computed tomography (CT) scans were performed every 7 days or earlier in case of fever and/or purulent nasal discharge. Criteria for nosocomial sinusitis were as follows: fever of > 38 degrees C, radiographic (sinusal air-fluid level or opacification on CT scan) signs and presence of purulent aspirate from the involved sinus puncture with 10(3) colony-forming units (cfu)/mL. Diagnosis of pneumonia was based on classical criteria and a protected brush specimen with 10(3) cfu/mL. MEASUREMENTS AND MAIN RESULTS: Radiographic evidence of sinusitis was observed in 78 patients, 45 from the nasal group and 33 from the oral group (p = .08, log-rank test). Among these patients, 54 fulfilled the sinusitis criteria stated above, 29 in the nasal group and 25 in the oral group (p = .75, log-rank test). Nosocomial pneumonia was observed in 26 patients, 17 in the nasal group and 9 in the oral group (p = .11, log-rank test). A multivariable analysis considering sinusitis as a time-dependent factor has suggested that sinusitis increased the risk of nosocomial pneumonia by a factor of 3.8. Nosocomial septicemia was observed in 33 patients, 22 episodes in the nasal group and 13 episodes in the oral group (p = .11, log-rank test). Overall mortality rate was 37% in the nasal group vs. 41% in the oral group (p = .37, log-rank test). Episodes of atelectasis and accidental extubations, and doses of sedative drugs and antibiotics were not different between the two groups. Length of mechanical ventilation did not differ between the two intubation groups. The mean length of stay in the ICU was 11 +/- 15 days in the nasal group vs. 9.5 +/- 11 days in the oral group (p = .27, Student's t-test). CONCLUSIONS: In patients undergoing prolonged mechanical ventilation, there was no statistically significant difference in the occurrence rate of nosocomial sinusitis or pneumonia between patients undergoing tracheal intubation via the nasal vs. oral route. A trend (p = 0.008) suggests less sinusitis in the orotracheal group.

Adult↗
PubMed1998

Portable devices used to detect endotracheal intubation during emergency situations: a review.

OBJECTIVES: To review the operational characteristics of commercial devices used to detect endotracheal intubation; and to identify an ideal device for detecting endotracheal intubation in emergency situations, especially in the prehospital setting during cardiac arrest. DATA SOURCES: Relevant articles from the medical literature are referenced. STUDY SELECTION: The authors identified the need for understanding the basic operation principles of portable devices used to detect endotracheal intubation and to correctly use them in unpredictable clinical situations. DATA EXTRACTION: Data from published literature. DATA SYNTHESIS: Recently, a number of new portable devices have been marketed for detecting endotracheal intubation, each having advantages and disadvantages, especially when used during emergency situations. The devices are classified based on their principle of operation. Some rely on CO2 detection (STATCAP, Easy Cap, and Pedi-Cap), others utilize the transmission of light (Trachlight, SURCH-LITE), one operates based on reflection of sound energy (SCOTI), and some depend on aspiration of air (TubeChek and TubeChek-B). A brief description of each device and its operational characteristics are reviewed. A comparative analysis among the devices is made based on size, portability, cost, ease of operation, need for calibration or regular maintenance, reliability for patients with and without cardiac arrest, and the possibility of use for adult and pediatric patients. False-negative and false-positive results for each device are also discussed. False-negative results mean that although the endotracheal tube is in the trachea, the device indicates it is not. False-positive results mean that although the endotracheal tube is in the esophagus, the device indicates it is in the trachea. CONCLUSIONS: Although no clinical comparative study of commercial devices to detect endotracheal intubation exists, the syringe device (TubeChek) has most of the characteristics necessary for a device to be considered ideal in emergency situations in the prehospital setting. It is simple, inexpensive, easy to handle and operate, disposable, does not require maintenance, gives reliable results for patients with and without cardiac arrest, and can be used for almost all age groups. The device may yield false-negative results, most commonly in the presence of copious secretions and in cases of accidental endobronchial intubation. Regardless of the device used, clinical judgment and direct visualization of the endotracheal tube in the trachea are required to unequivocally confirm proper endotracheal tube placement.

Capnography↗
PubMed1997

Posttraumatic distress in children and families after intubation.

BACKGROUND: Posttraumatic stress disorder symptoms are seen in children who have experienced significant trauma. Respiratory arrest with subsequent intubation can be associated with terror, helplessness, and the threat of death. METHODS: Three case reports are presented where emergency intubation was followed by symptoms of psychologic distress in the intubated child and his or her family members. RESULTS: Although the medical literature documents posttraumatic distress symptoms after other medical procedures, this is the first account of symptoms following intubation. Children and other family members were found to have symptoms of reexperiencing the traumatic event, avoidance of thoughts or feelings related to the intubation, and hyperarousal. Issues around diagnosis and treatment are discussed. CONCLUSIONS: Children with a history of emergency intubation should be evaluated for possible posttraumatic stress disorder symptoms.

Child↗
PubMed1980

Risk of bacteremia after endotracheal intubation for general anesthesia.

Blood cultures were obtained before and after endotracheal intubation to assess the risk of bacteremia associated with this procedure and to evaluate the need for prophylactic antibiotics to prevent bacterial endocarditis in patients with structural heart disease requiring general anesthesia. Blood cultures were obtained immediately before intubation and two and ten minutes after intubation in 50 individuals without evidence of structural heart disease who required general anesthesia for elective surgery. Of 32 who had orotracheal intubation, only one demonstrated postintubation bacteremia; of 18 individuals who had nasotracheal intubation, none had evidence of bacteremia. These data suggest that in healthy individuals undergoing endotracheal intubation under direct vision the risk of bacteremia is quite small (about 2%).

Adolescent↗
PubMed2005

Dexmedetomidine and awake fiberoptic intubation for possible cervical spine myelopathy: a clinical series.

For many anesthesiologists, awake fiberoptic endotracheal intubation (AFOBI) is the preferred method of intubation when treating patients with symptoms or signs of cervical spinal cord compression. The advantage of this method is to minimize cervical spine movements that could contribute to neurologic impairment. In patients who are anxious or poorly cooperative, adequate sedation in addition to topicalization of the airway may be key to minimize patient discomfort and assist in successful intubation, but imposes the risk of respiratory depression. Dexmedetomidine has the advantage of producing sedation without a significant decrease in respiratory drive. We are now reporting our experience of a series of AFOBI using dexmedetomidine for sedation. A retrospective chart review was conducted on the anesthetic records of patients, who had undergone an awake fiberoptic endotracheal intubation (AFOBI) using dexmedetomidine for sedation. These were patients in whom AFOBI was indicated because of signs or symptoms of cervical spinal cord compression. Dexmedetomidine provided adequate sedation. We did not encounter any loss of airway or airway obstruction during the intubation. The patients had excellent cooperation for post-intubation neurologic examination. Thirteen patients developed transient hypotension after induction of general anesthesia that was managed with boluses of phenylephrine or ephedrine.

Adrenergic alpha-Agonists↗
PubMed2004

Double silicone intubation as treatment for persistent congenital nasolacrimal duct obstruction.

PURPOSE: The great majority of children with nasolacrimal duct (NLD) obstruction are successfully treated with probing or conventional silicone tube intubation. A small percentage of patients fail to have their NLD obstruction resolved with these procedures and require dacryocystorhinostomy (DCR). This study was conducted to assess the effectiveness of double bicanalicular silicone intubation with placement of two loops of silicone tubing through the NLD for treatment of persistent NLD obstruction in children as an alternative to DCR. METHODS: Ten eyes of 9 patients with nasolacrimal duct obstruction who had failed conventional therapies and were to otherwise undergo DCR were instead treated with double bicanalicular silicone tube intubation. Resolution of preoperative symptoms and signs of NLD obstruction were assessed. RESULTS: At an average follow-up of 40 +/- 5.6 months, all patients had improvement in symptoms and signs. The mean patient age was 31 +/- 3.2 months. The average duration of intubation was 15 +/- 0.73 months. Eight of 10 eyes had complete resolution of NLD obstruction symptoms. Two of 10 treated eyes had occasional symptoms of mattering with upper respiratory infection and exposure to wind or cold but required no further treatment. Nine of 10 eyes were treated for congenital NLD obstruction. The remaining patient had failed conventional bicanalicular intubation after repair of a traumatic common canalicular avulsion. CONCLUSIONS: Double bicanalicular silicone tube intubation is an effective alternative to DCR in selected children who have failed conventional therapies for NLD obstruction. This treatment obviated DCR in all patients in this study.

Biocompatible Materials↗
PubMed2004

Oropharyngeal aspiration in pediatric patients with endotracheal intubation.

OBJECTIVE: To determine the prevalence and factors associated with oropharyngeal aspiration in pediatric patients submitted to mechanical ventilation and endotracheal intubation. DESIGN: Prospective cross-sectional study. SETTING: Four pediatric intensive care units. PATIENTS: Fifty infants and children with endotracheal intubation submitted to mechanical ventilation. INTERVENTIONS: Aspiration was determined by administering Evans blue dye in the oral cavity and searching the dye agent in the specimens obtained from two tracheal aspirates performed at 5- and 30-min intervals. During this period, the frequency of swallowing movements was continuously monitored using surface electromyography (biofeedback). The association between aspiration and age, sedation level, mean airway pressure, swallowing dynamics, and intubation route was tested using the chi-square and relative risk (95% confidence interval). Results also were adjusted by multivariate analysis. MEASUREMENTS AND MAIN RESULTS: The overall prevalence of aspi-ration was 28% (n = 14). At the univariate analysis, aspiration was associated with sedation level (p =.03), frequency of swallowing movements (p =.0003), and orotracheal route (p =.03). The relative risk (95% confidence interval) for aspiration was 2.92 (1.32-6.42) in patients considered to be inadequately sedated (Hartwig 8-18); 14.08 (1.99-99.67) in patients presenting frequent swallowing (>30 movements in 30 mins); and 5.57 (0.8-38.85) in patients with orotracheal intubation. The multivariate analysis identified that the orotracheal route (p =.03) and frequent swallowing movements (p =.0007) were independently associated with aspiration. CONCLUSIONS: Aspiration around the tracheal tube is a frequent finding (28%) in children undergoing mechanical ventilation. The frequent swallowing movements and the orotracheal intubation route were significantly associated with aspiration. These results suggest that the nasotracheal intubation route could be recommended as the first choice for reducing this potential clinical complication.

Child↗
PubMed2004

Blind nasotracheal intubation for patients with penetrating neck trauma.

BACKGROUND: Early airway management is advocated for patients with penetrating neck trauma who have any signs of airway compromise. This study examined the clinical course of patients with penetrating neck trauma who received prehospital blind nasotracheal intubation, including successful intubation rates, and outcomes. METHODS: A retrospective review of patients admitted to the emergency department for penetrating neck trauma was conducted from January 1, 1993 to July 1, 2001 at the Denver Health Medical Center. Patients were identified from the trauma registry, and data were collected using standardized inclusion and exclusion criteria. RESULTS: The study identified 240 patients with penetrating neck trauma. Overall mortality was 8.3%. Among the 240 patients, 89 (37%) required airway management, and 40 (17%) underwent prehospital management with blind nasotracheal intubation. The success rate for prehospital intubation using the blind nasotracheal method was 90%. The mean number of attempts was 1.16 (range, 1-4), and the mortality in this group was 5%. CONCLUSION: The patients managed with blind nasotracheal intubation did not experience complications related to the choice of airway management. Despite prior warnings in the literature, the results of this study suggest that blind nasotracheal intubation may well be a valuable tool for the management of patients with penetrating neck trauma.

Academic Medical Centers↗
PubMed2004

Rapid sequence intubation of trauma patients in Scotland.

BACKGROUND: Endotracheal intubation remains the gold standard for trauma airway management. Rapid sequence intubation (RSI) has traditionally been performed by anesthesiologists but increasingly, emergency physicians are also undertaking RSI. We aimed to compare success and complication rates for trauma intubations for the two specialties. METHODS: Two year, prospective multi-center descriptive study of trauma RSI in seven Scottish urban emergency departments. RESULTS: 439 trauma patients were identified, including 233 RSIs. Patients intubated by emergency physicians had a higher median ISS (p < 0.001) and lower median RTS (p < 0.001) compared with anesthesiologists. For RSI, anesthesiologists had more grade I & II views at laryngoscopy (p = 0.051) and more successful first attempt intubations (p = 0.034) but there was no difference in the number of patients suffering complications (emergency physicians 10.0%, anesthesiologists 10.6%). CONCLUSION: There is no significant difference in complication rates for trauma RSI between emergency physicians and anesthesiologists in Scottish urban centers. A collaborative approach to the critical trauma airway is vital. Emergency physicians should consult with senior anesthesiologists before RSI when intubation is predicted to be difficult.

Adult↗
PubMed1989

Cardiovascular effects of fibrescope-guided nasotracheal intubation.

The cardiovascular effects of fibrescope-guided nasotracheal intubation were compared to those of a control group of patients who were intubated using the Macintosh laryngoscope. The 60 patients studied received a standard anaesthetic technique which included a muscle relaxant and were allocated randomly to one of two groups immediately before tracheal intubation. Systolic and diastolic arterial pressures in the fibreoptic group were significantly lower than in the control group during the first minute after intubation. The maximum increase in diastolic pressure was significantly lower in the fibreoptic group. The heart rate in the fibreoptic group was significantly higher than in the control group during all five minutes after intubation. The maximum increase in heart rate was significantly higher in the fibreoptic group. The cardiovascular responses to fibreoptic nasotracheal intubation under general anaesthesia should not cause undue concern in fit patients, but appropriate measures should be taken to prevent excessive tachycardia in compromised patients.

Adult↗