European Journal of Anaesthesiology:
December 2016 - Volume 33 - Issue 12 - p 881–897
doi: 10.1097/EJA.0000000000000533

Emergency anaesthesia is an important therapeutic measure in out-of-hospital emergency medicine. The associated risks are considerably higher than those of in-hospital anaesthesia. The primary objectives of emergency anaesthesia are hypnosis, analgesia, oxygenation and ventilation through airway management. The secondary objectives of emergency anaesthesia are amnesia, anxiolysis, the reduction of oxygen consumption and respiratory work, the protection of vital organs and the avoidance of secondary myocardial and cerebral damage. A critical evaluation of the indications for out-of-hospital emergency anaesthesia must take into consideration patient, case and provider-related factors. Rapid sequence induction of emergency anaesthesia includes standard monitoring, preoxygenation, standardised preparation of emergency anaesthesia, drug administration, manual in-line stabilisation during intubation (if necessary), airway management and checking of correct tube placement. Spontaneously breathing casualties should receive preoxygenation for at least 3 to 4 min with a tight-fitting facemask with reservoir using 12 to 15 l min_1 of oxygen or with a demand valve providing 100% oxygen. As an alternative, preoxygenation may be performed as noninvasive ventilation with 100% oxygen. Standardised anaesthesia preparation comprises filling drugs into syringes and labelling them, checking ventilation equipment, preparing endotracheal tube and syringe for inflating the cuff and the introducer, stethoscope and fixation material, preparing alternative instruments for airway management as well as checking suction, ventilation and standard monitoring devices, including capnography. Standard monitoring for out-of-hospital emergency anaesthesia comprises ECG, blood pressure measurement and pulse oximetry. Continuous capnography is always and exclusively performed to check the placement of airway devices, as well as to indirectly monitor haemodynamics.

British Journal of Anaesthesia, Volume 117, suppl 1, September 2016.

In this special issue of the BJA, a free and open access collection of editorials, review articles and original articles on airway management are found, together with selected abstracts presented at the World Airway Management Meeting (November 2015, Dublin).

​Ann Emerg Med. 2015 Apr;65(4):363-370

STUDY OBJECTIVE: We describe the operators, techniques, success, and adverse event rates of adult emergency department (ED) intubation through multicenter prospective surveillance.

METHODS: Eighteen EDs in the United States, Canada, and Australia recorded intubation data onto a Web-based data collection tool, with a greater than or equal to 90% reporting compliance requirement. We report proportions with binomial 95% confidence intervals (CIs) and regression, with year as the dependent variable, to model change over time.

RESULTS: Of 18 participating centers, 5 were excluded for failing to meet compliance standards. From the remaining 13 centers, we report data on 17,583 emergency intubations of patients aged 15 years or older from 2002 to 2012. Indications were medical in 65% of patients and trauma in 31%. Rapid sequence intubation was the first method attempted in 85% of encounters. Emergency physicians managed 95% of intubations and most (79%) were physician trainees. Direct laryngoscopy was used in 84% of first attempts. Video laryngoscopy use increased from less than 1% in the first 3 years to 27% in the last 3 years (risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year [ie, slope] 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine in 75% of rapid sequence intubations. Among rapid sequence intubations, rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3 years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last 3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2% to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI 99.3% to 99.6%).

CONCLUSION: In the EDs we studied, emergency intubation has a high and increasing success rate. Both drug and device selection evolved significantly during the study period.

Acad Emerg Med. 2016 Apr;23(4):433-9. 

​BACKGROUND: Direct laryngoscopy (DL) has long been the most common approach for emergency endotracheal intubation, although the use of video laryngoscopy (VL) is becoming more widespread. Current observational data suggest that VL has higher first-pass success, although randomized trials are lacking.

OBJECTIVES: The objective was to compare first-pass success in patients undergoing emergency intubation with DL or VL using a C-MAC device.

METHODS: This was an open-label, prospective, randomized, controlled trial in an academic emergency department of patients undergoing emergency intubation with a plan of DL for the first attempt. Patients were randomly assigned in a 1:1 ratio to either DL or VL using a C-MAC device for the first intubation attempt. The primary outcome was first-pass success. Secondary outcomes included time to intubation, development of aspiration pneumonia, and hospital length of stay (LOS). The study was registered at Clinicaltrials.gov, number NCT01710891.

​RESULTS:A total of 198 patients were enrolled and intubated with either DL (n = 95) or VL (n = 103). First-attempt success was 86 and 92% for the DL and VL groups, respectively (difference = -5.9%, 95% confidence interval = -14.5% to 2.7%, p = 0.18). Time to intubation, rates of aspiration pneumonia, and hospital LOS were not different between the two groups.

CONCLUSIONS: In patients undergoing emergency intubation in whom DL was planned for the first attempt, we did not detect a difference between VL or DL using the C-MAC device in first-pass success, duration of intubation attempt, aspiration pneumonia, or hospital LOS.

Scand J Trauma Resusc Emerg Med. 2014 Sep 11;22(1):41.

Introduction Rapid sequence induction (RSI) of critically ill patients outside of theatres is associated with a higher risk of hypoxia, cardiovascular collapse and death. In the prehospital and military environments, there is an increasing awareness of the benefits of standardised practice and checklists.

Methods We conducted a non-systematic review of literature pertaining to key components of RSI preparation and management. A standard operating procedure (SOP) for in-hospital RSI was developed based on this and experience from large teaching hospital anaesthesia and critical care departments.

Results The SOP consists of a RSI equipment set-up sheet, pre-RSI checklist and failed airway algorithm. The SOP should improve RSI preparation, crew resource management and first pass intubation success while minimising adverse events.

Conclusion Based on the presented literature, we believe the evidence is sufficient to recommend adoption of the core components in the suggested SOP. This standardised approach to RSI in the critically ill may reduce the current high incidence of adverse events and hopefully improve patient outcomes.