A novel publication goes to enrich the long-living debate on direct laryngoscopy (DL) vs video laryngoscopy (VL) efficacy in emergency intubation.
The recent article, pubblished on JEMS and titled “Deploying the Video Laryngoscope into a Ground EMS System” ,compares the success rate beetwen DL vs VL in a ground EMS Service. The device used was the King Vision with channeled blade. The partecipants had a prior training on the divide, consisting in didactic orientation and practical skills on manikins.
The result of the study shown that “Within the first 100 days of the study, the video laryngoscope utilizing the channeled blade has shown to be at least as effective as DL in relation to first-attempt success” and considering that “the mean experience in our group with DL is nine years, yet the success rate remains unacceptable” “It’s time to consider transition from a skill that’s difficult to obtain and maintain to one that appears to have a quicker learning curve and will likely result in decreased episodes of multiple attempts at intubation and associated complications.”
So is direct laryngoscopy dead?( Or will be so in a few years)
Here are some considerations
There are some fundamental differences in VL tecnique respect the DL tecnique, that makes the DL more intuitive to pass the tube trough the cords.
We have basically 3 main axis in the airways
When we manage the airways we first put the head in “sniffing position” aligning the pharyngeal axis with the laryngeal one
Then we use the laryngoscope to align the mouth axis having so a direct view of the cords. This view coincide with the way to pass the tube, making this step intitive and easy.
When using the videolaryngoscope we take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.
For this reason passing the OTT is not straight forward, so we need the stylet, the Bougie/Froban or the external glottic maneuvers, to facilitate the intubation.
This difference in tecnique makes the VL not so intuitive due to the contrast between the perfect laryngeal view and the not intuitive passage of the tube trough the cords.
In fact the available evidences almost accordingly demonstrate an equivalent success first pass rate beetwen traditional laryngoscope an video but a prolonged intubation time in VL groups.
As the previously cited article demonstrate the learning curve for VL is short and easy to perform, and this make this tecnique surely suitable for emergency intubation.
But for emergency professionals well trained and familiar with DL I think this has to be the first choice approach when managing an emergent airway.
Emergency field is not the place to make trianing or experience with novel devices or drugs.
The still not widely availability of video-laryngoscope makes this device a perfect alternative in all the casess when is not possible to obtain a good laryngela view with DL, but still not the gold standard tecnique.
In the future the increasingly diffusion of videoleryngoscopes (due mostly to more affordable prices), will chenge the airway management scenario. Novel emergency medicine operators will grown up parallel experience wid DL and VL so the latter will be more suitable as first choice device.
Bottom line
Wich way you prefer to go home?
The quickest and the shorter one for sure!
Do you use the GPS to go home?
Agree, me neither!
And when you use it?
Right! When you are lost!
So that’s why Direct Laryngoscope il still my Plan A
My straight way home!
Tags: Airway management, emergency medicine, medicina d'urgenza, medicina d'urgenza preospedaliera, prehospital emergency medicine, videolaryngoscopy
The second episode of this focus reviews will deeply assess a topic that is very “hot” for every emergency professional. 
Le tue opinioni sono il nostro valore aggiunto!
MEDEST 
F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #3: Trauma
10 Jan#1 Cardiac Arrest
#2 Airway Management
In this episode we’ll explore the best articles of 2014 about:
Trauma
Before approaching specific arguments about trauma here are some fundamental articles to read about new emerging concepts in trauma care. Those are the clinical and physiological bases to understand what is happening in the actual trauma management scene.
Trauma-Induced Coagulopathy
Pre-hospital identification of trauma patients with early acute coagulopathy and massive bleeding: results of a prospective non-interventional clinical trial evaluating the Trauma Induced Coagulopathy Clinical Score (TICCS)
Development of a simple algorithm to guide the effective management of traumatic cardiac arrest (read also Mind of resuscitation in traumatic cardiac arrest)
Damage Control Resuscitation in Trauma
The Management of Pediatric Polytrauma: Review
And now let’s go to specific area of interest:
Spine immobilization
Spine immobilization in trauma is changing.
After years of dogmatic approach to strict spine immobilization for all trauma patients regardless any other factor, is now pretty clear that not all the trauma patients benefits from this all or nothing way of thinking. MEDEST already faced the argument in previous posts (The Death of the Cervical Collar?) as also did some prehospital consensus guidelines (Faculty of Pre-Hospital Care Consensus Statements).
In 2014 many articles treated this topic in a critical and modern way of re-thinking spinal immobilization, in particular the widespread use of cervical collar. The lessons we learned is that:
Cost-utility analysis of prehospital spine immobilization recommendations for penetrating trauma
Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma
Prehospital Use of Cervical Collars in Trauma Patients- A Critical Review
Comparison of Three Prehospital Cervical Spine Protocols for Missed Injuries
Fluids and blood products
What is “revolution” in clinical practice? We don’t have the answer to this dilemma, but what is happening in fluid resuscitation for trauma patients seems likely to be revolutionary. Restrictive strategies and new blood products are the future for the treatment of trauma patients (read also Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?).
Liberal Versus Restricted Fluid Resuscitation Strategies in Trauma Patients
Fluid resuscitation in trauma patients- what should we know
Pretrauma Center Red Blood Cell Transfusion Is Associated With Reduced Mortality and Coagulopathy in Severely Injured Patients With Blunt Trauma
The Ongoing Debate Between Crystalloid and Colloid
Fluid Resuscitation for Trauma Patients: Crystalloids Versus Colloids
Hypotensive Resuscitation
Trauma and Massive Blood Transfusions
Is early transfusion of plasma and platelets in higher ratios associated with decreased in-hospital mortality in bleeding patients?
The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study
But much more happened in 2014 about trauma….
Resuscitative throacotomy is now a reality not only “in” but even “out” of hospital, so read all about it
Resuscitative thoracotomy an update
An evergreen topic is TBI but new concepts are arousing so read here the latest updates
Critical care management of severe traumatic brain injury in adults
New drugs and new protocols for airway and pain management: a rationale guide to choose the right drug for the right patient.
Choice of General Anesthetics for Trauma Patients
Pain management in trauma patients in (pre)hospital based emergency care: Current practice versus new guideline
DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.
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Tags: ACR, advanced airway management, Antiaggregazione, antiplatelets, arresto cardiaco, clinical decision rules, emergency medicine, emergenza sanitaria territoriale, gestione avanzata delle vie aeree, litterature review, medicina d'urgenza, prehospital emergency medicine, sindromi coronariche acute, Stroke