Jacek Smereka

A comparison of a traditional endotracheal tube versus Etview Sl in endotracheal intubation during different emergency conditions: A randomized, crossover cadaver trial

Background:Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR. Methods:ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario. Results:The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5–22] sec, when compared to that of sETT at 21.5 [IQR, 20–25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5–24.5] sec (p < .001) and sETT was 27 [IQR, 24.5–31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19–25.5] sec for the ETView and 42.5 [IQR, 35–49.5] sec for sETT. Conclusions:In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were improved with the ETView. The time to glottis view, tube insertion, and cuff block were all found to be shorter with the ETView. Trial Registration:clinicaltrials.gov Identifier: NCT02733536.

C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: A manikin trial

Introduction The aim of this study was to compare C‐MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. Methods The study was designed as a prospective randomized crossover manikin trial. 70 paramedics with < 5 years of medical experience participated in the study. The paramedics attempted to intubate manikins in 3 airway scenarios: normal airway without cervical immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). Results Scenario A: Nearly all participants performed successful intubations with both MAC and C‐MAC on the first attempt (95.7% MAC vs. 100% C‐MAC), with similar intubation times (16.5 s MAC vs. 18 s C‐MAC). Scenario B: The results with C‐MAC were significantly better than those with MAC (p < 0.05) for the time of intubation (23 s MAC vs. 19 s C‐MAC), success of the first intubation attempt (88.6% MAC vs. 100% C‐MAC), Cormack‐Lehane grade, POGO score, severity of dental compression, device difficulty score, and preferred airway device. Scenario C: The results with C‐MAC were significantly better than those with MAC (p < 0.05) for all the analysed variables: success of the first attempt (51.4% MAC vs. 100% C‐MAC), overall success rate, intubation time (27 s MAC vs. 20.5 s C‐MAC), Cormack‐Lehane grade, POGO score, dental compression, device difficulty score and the preferred airway device. Conclusion The C‐MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization.

Comparison of the Trachway video intubating stylet and Macintosh laryngoscope for endotracheal intubation. Preliminary data

Sir, The ability to perform airway management and maintain adequate ventilation of the patient are the key elements during cardiopulmonary resuscitation. Current European Resuscitation Council guidelines indicate the endotracheal intubation are the gold standard for airway control in adults during CPR [1]. However, as indicated by numerous scientific studies, the effectiveness of endotracheal intubation with direct laryngoscopy performed during resuscitation is inadequate [2,3, 4]. Therefore, it seems reasonable to search for alternative methods of endotracheal intubation, which are likely to increase the intubation effectiveness and reduce the total time of the procedure. The aim of the study was to compare two methods of endotracheal intubation performed by novice physicians during simulated CPR. Before the study, all the participants took part in a 10-minute training on the correct use of Trachway video intubating stylet (TVI, TVI4000, Markstein Sichtec Medical Corp., Taichung, Taiwan) and Macintosh laryngoscope (MACMercuryMedical, Clearwater, FL, USA). Intubation was performed on MegaCode KellyTM advanced life support manikin (Laerdal Medical, Stavanger, Norway), which was situated on a flat floor in a bright room. Intubation was performed during uninterrupted chest compressions. Due to the fact that the quality of chest compressions varies among medical staff [5,6], in order to standardize the difficulties arising from intubation duringuninterrupted chest compressions we used mechanical chest compression device Lifeline ARM (Defibtech, USA). In the main study, both the order of participants and the study methods were random. Participants had up to three endotracheal intubation attempts, after the procedure had a 10-minute break, and then performed endotracheal intubation using other method. The

Clinical relevance of syncope and presyncope induced by tilt testing.

Objective — The authors investigated the relation between presyncope and syncope induced by tilt testing (HUTT) and demographics, medical history and HUTT data.The demographics, syncopal burden, data regarding the spontaneous syncope and reproduction of symptoms during HUTT were compared among patients with induced syncope and presyncope. The study group consisted of 574 patients (371 women, 203 men), aged 43.7 ± 18.5 years. Methods and results — Patients with syncope induced by HUTT (418 patients, 63.9% women) had a higher number of syncopal episodes in their medical history. Stepwise logistic regression revealed that syncope provocation was independently related to the cardiodepressive type of neuro-cardiogenic reaction (OR 7.8, CI 4.2-14.4, P < 0.001), NTG use (OR 1.7, CI: 1.0-2.7, P < 0.05), the reproduction of the symptoms during HUTT (OR 2.0, CI: 1.3-3.1, P < 0.01) and the higher number of syncopal episodes (OR 2.0, CI: 1.3-3.0, P < 0.01). In patients with positive HUTT during a passive phase it was related to the cardiodepressive type of reaction (OR 26.5, CI: 5.9-118.5, P < 0.001). In the group with positive HUTT after NTG syncope was related to the cardiodepressive type (OR 5.7, CI: 2.9-11.2, P < 0.001), vasovagal history (OR 2.0, CI: 1.2-3.3, P < 0.01), reproduction of the spontaneous symptoms (OR 1.9, CI: 1.1-3.1, P < 0.05) and higher number of syncopal episodes (OR 2.1, CI: 1.3-3.3, P < 0.01). Conclusions — Syncope is more frequently a HUTT outcome than presyncope.The provocation of syncope in the passive phase of HUTT depends only on the cardiodepressive type of neuro-cardiogenic reaction. The induction of presyncope after nitroglycerin provocation is related to the possibility of a false positive reaction.

A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: A randomized manikin study

Introduction: Pediatric cardiac arrest is an uncommon but critical life‐threatening event requiring effective cardiopulmonary resuscitation. High‐quality cardio‐pulmonary resuscitation (CPR) is essential, but is poorly performed, even by highly skilled healthcare providers. The recently described two‐thumb chest compression technique (nTTT) consists of the two thumbs directed at the angle of 90° to the chest while having the fingers fist‐clenched. This technique might facilitate adequate chest‐compression depth, chest‐compression rate and rate of full chest‐pressure relief. Methods: 42 paramedics from the national Emergency Medical Service of Poland performed three single‐rescuer CPR sessions for 10 minutes each. Each session was randomly assigned to the conventional two‐thumb (TTHT), the conventional two‐finger (TFT) or the nTTT. The manikin used for this study was connected with an arterial blood pressure measurement device and blood measurements were documented on a 10‐seconds cycle. Results: The nTTT provided significant higher systolic (82 vs. 30 vs. 41 mmHg). A statistically significant difference was noticed between nTTT and TFT (p<.001), nTTT and TTHT (p < 0.001), TFT and TTHT (p = 0.003). The median diastolic preassure using nTTT was 16 mmHg compared with 9 mmHg for TFT (p < 0.001), and 9.5 mmHg for TTHT (p < 0.001). Mean arterial pressure using distinct methods varied and amounted to 40 vs. 22. vs. 26 mmHg (nTTT vs. TFT vs. TTHT, respectively). A statistically significant difference was noticed between nTTT and TFT (p < 0.001), nTTT and TTEHT (p < 0.001), and TFT and TTHT (p < 0.001). The highest median pulse pressure was obtained by the nTTT 67.5 mmHg. Pulse pressure was 31.5 mmHg in the TTHT and 24 mmHg in the TFT. The difference between TFT and TTHT (p = 0.025), TFT and nTTT (p < 0.001), as well as between TTHT and nTTT (p < 0.001) were statistically significant. Conclusions: The new nTTT technique generated higher arterial blood pressures compared to established chest compression techniques using an infant manikin model, suggesting a more effective chest compression. Our results have important clinical implications as nTTT was simple to perform and could be widely taught to both healthcare professionals and bystanders. Whether this technique translates to improved outcomes over existing techniques needs further animal studies and subsequent human trials.

Comparison of Macintosh and Intubrite laryngoscopes for intubation performed by novice physicians in a difficult airway scenario

Introduction: In the difficult airway, the intubation skills are critically important. In selected cases, particularly in airway edema, laryngeal or tongue edema, endotracheal intubation can turn out very difficult, and repeated attempts may even worsen the airway edema, causing trauma and bleeding, and finally leading to complete airway obstruction and inability to ventilate the patient. Aim of the study: The aim of the study was to compare the efficacy of endotracheal intubation performed by novice physicians using a standard Macintosh laryngoscope and an Intubrite videolaryngoscope. Material and methods: The study was designed as a prospective, randomized, crossover, simulation study and continues our research assessing the effectiveness of selected endotracheal intubation techniques in prehospital settings. All participants were experienced with the Macintosh direct laryngoscope but remained novice to videolaryngoscopy. Instructions on the correct use of the Macintosh and Intubrite laryngoscopes were given before the procedure, and all the 30 novice physicians were allowed to practice at least 10 times before the study on manikin with normal airways. We employed an airway manikin (Trucorp Airsim Bronchi; Trucorp Ltd., Belfast, Northern Ireland) to simulate difficult airway, with was obtained by inflating the tongue with 50 mL of air. The participants were asked to perform tracheal intubation using an endotracheal tube with 7.5 mm of internal diameter (Portex; Smiths Medical, Hythe, UK) through the vocal cords, applying either a conventional Macintosh laryngoscope with a size 3 blade (MAC; Mercury Medical, Clearwater, FL, USA) or the Intubrite videolaryngoscope, also with a Macintosh No. 3 blade (INT; Intubrite Llc, Vista, CA, USA). In both intubation techniques, a guide stylet (Rusch Inc., Duluth, GA, USA) was introduced into the endotracheal tube in order to obtain a C‐shape curve to facilitate tracheal intubation. Each participating physician was randomly assigned to three attempts of tracheal intubation with each device. Results: The effectiveness of the first intubation attempt using MAC and INT was 63.6% and 53.4%, respectively (p = 0.023), and the total percentage of intubation was 100% for both methods. The median time to intubation was 29.5 (interquartile range [IQR], 27–35.5) s with MAC, and 229 (IQR, 25.5–37) s with INT. The total of 24 physicians out of all study participants would choose MAC as a device to intubate with in real terms, while only 6 physicians would choose INT. Conclusions: During the simulation study, the novice physicians were able to perform endotracheal intubation at the same time using both the Macintosh and Intubrite videolaryngoscope. However, the efficacy of the first intubation attempt was higher for MAC. Further studies are needed to confirm the results.

Comparison of the Macintosh laryngoscope and blind intubation via the iGEL for Intubation With C-spine immobilization: A Randomized, crossover, manikin trial

Introduction: Endotracheal intubation (ETI) using a Macintosh laryngoscope (MAC) requires the head to be positioned in a modified Jackson position, slightly reclined and elevated. Intubation of trauma patients with an injured neck or spine is therefore difficult, since the neck usually cannot be turned or is already immobilized in order to prevent further injury. The iGEL supraglottic airway seems optimal for such conditions due to its blind insertion without the need of a modified Jackson position. Methods: Prospective, randomized, crossover study in 46 paramedics. Participants performing standard intubation and blind intubation via iGEL supraglottic airway device in three airway scenarios: Scenario A – normal airway; Scenario B ‐ manual inline cervical immobilization, performed by an independent instructor; scenario C: cervical immobilization using a standard Patriot cervical extraction collar. Results: In Scenario A, nearly all participants performed ETI successfully both with MAC and iGEL (100% vs. 95.7%). The time to intubation (TTI) using the MAC and iGEL amounted to 19 [IQR, 18–21]s vs. 12 [IQR, 11–13]s (P < 0.001). Head extension angle as well as tooth compression were significantly better with the iGEL compared to the MAC (P < 0.001). In scenario B and C, the results with the iGEL were significantly better than with MAC for all analyzed variables (TTI, success of first intubation attempt, head extension angle, tooth compression and VAS scores). Conclusion: We showed that blind intubation with the iGEL supraglottic airway was superior to ETI performed by paramedics in a simulated cervical immobilization scenario in a manikin in terms of success rate, time to definite tube placement, head extension angle, tooth compression, and rating.

A Randomized Cadaver Study Comparing First-Attempt Success Between Tibial and Humeral Intraosseous Insertions Using NIO Device by Paramedics: A Preliminary Investigation.

Abstract Medical personnel may encounter difficulties in obtaining intravenous (IV) access during cardiac arrest. The 2015 American Heart Association guidelines and the 2015 European Resuscitation Council guidelines for cardiopulmonary resuscitation (CPR) suggest that rescuers establish intraosseous (IO) access if an IV line is not easily obtainable. The aim of the study was to compare the success rates of the IO proximal tibia and proximal humerus head access performed by paramedics using the New Intraosseous access device (NIO; Persys Medical, Houston, TX, USA) in an adult cadaver model during simulated CPR. In an interventional, randomized, crossover, single-center cadaver study, a semi-automatic spring-load driven NIO access device was investigated. In total, 84 paramedics with less than 5-year experience in Emergency Medical Service participated in the study. The trial was performed on 42 adult cadavers. In each cadaver, 2 IO accesses to the humerus head, and 2 IO accesses to the proximal tibia were obtained. The success rate of the first IO attempt was 89.3% (75/84) for tibial access, and 73.8% (62/84) for humeral access (P = 0.017). The procedure times were significantly faster for tibial access [16.8 (interquartile range, IQR, 15.1–19.9] s] than humeral access [26.7 (IQR, 22.1–30.9) s] (P < 0.001). Tibial IO access is easier and faster to put in place than humeral IO access. Humeral IO access can be an alternative method to tibial IO access. Trial Registration: clinicaltrials.gov Identifier: NCT02700867.

Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes☆☆☆★

OBJECTIVE The aim of the trial was to compare the time parameters for intubation with the use of the Macintosh (MAC) laryngoscope and Pentax AWS-S100 videolaryngoscope (AWS; Pentax Corporation, Tokyo, Japan) with and without chest compression (CC) by paramedics during simulated cardiopulmonary resuscitation in a cadaver model. METHODS This was a randomized crossover cadaver trial. Thirty-five paramedics with no experience in videolaryngoscopy participated in the study. They performed intubation in two emergency scenarios: scenario A, normal airway without CC; scenario B, normal airway with continuous CC. RESULTS The median time to first ventilation with the use of the AWS and the MAC was similar in scenario A: 25 (IQR, 22-27) seconds vs. 24 (IQR, 22.5-26) seconds (P=.072). A statistically significant difference in TTFV between AWS and MAC was noticed in scenario B (P=.011). In scenario A, the first endotracheal intubation (ETI) attempt success rate was achieved in 97.1% with AWS compared with 94.3% with MAC (P=.43). In scenario B, the success rate after the first ETI attempt with the use of the different intubation methods varied and amounted to 88.6% vs. 77.1% for AWS and MAC, respectively (P=.002). CONCLUSIONS The Pentax AWS offered a superior glottic view as compared with the MAC laryngoscope, which was associated with a higher intubation rate and a shorter intubation time during an uninterrupted CC scenario. However, in the scenario without CC, the results for AWS and MAC were comparable.

Comparison of the ETView Single Lumen and Macintosh laryngoscopes for endotracheal intubation in an airway manikin with immobilized cervical spine by novice paramedics: A randomized crossover manikin trial

Context: Management of the airway of a trauma victim is considered challenging. Various approaches have been described to achieve airway control in this setup; many of them include video-assited viewing of the larynx during intubation. ETView Single Lumen (SL) is a novice single-use endotracheal tube equiped with a video camera and a light source at its distal tip. Its use was previously described in seeral clinical and training setups. Objective: The aim was to evaluate the efficacy of the VivaSight SL compared with classic direct laryngoscopy performed with a Macintosh blade in a manikin-simulated trauma setup presenting various degrees of airway challenge when performed by inexperienced physicians. Design, Setting, Participants: This was prospective, randomized, crossover, manikin trial. After short training on the ETView system, 67 novice paramedics attempted to perform oral intubation using both standard direct laryngoscopy (MAC group) and the VivaSight SL endotracheal tube (ETView group) in a randomized order on manikins in 3 increasingly more difficult scenarios (simple intubation, cervical spine manual stabilization, and with cervical collar in place). Outcome Measure: Overall success rate, time to intubation, number of intubation attempts, laryngeal view grade, dental compression, and overall participant satisfaction were monitored. Results: Duration of intubation and number of attempts were significantly superior in the ETView group in the latter 2 more challenging scenarios. All other parameters showed superiority to the ETView group in all 3 scenarios. Conclusion: The VivaSight SL system performed better in a complex scenario of airway management of a trauma victim in need for cervical spine stabilization performed by novice caregivers compared to standard direct laryngoscopy and should be considered in this clinical setup.