Paul E. Berkebile

Use of a Lighted Stylet for Guided Orotracheal Intubation in the Prehospital Setting

Management of the airway in acutely injured patients demands special skills of the emergency physician. A technique of light-guided orotracheal intubation has been described in the literature and was performed under protocol by resident physicians in an urban mobile intensive care system. The method utilizes a flexible lighted stylet to provide a guide to correct placement through transillumination of the soft tissues of the neck. During the 12-month period of the study, 24 intubations were attempted in 21 patients using this technique. Twenty-one attempts (88%) were successful. The average time for intubation was 20 seconds, with none requiring more than 45 seconds. Fourteen intubations (67%) were successful on the first attempt. Of the three unsuccessful procedures, two were attempted in bright sunlight, and all three patients had vomited prior to the attempts. Trauma to the soft tissues in one successfully intubated patient was the only complication reported with the technique. The advantages of this method, including rapidity of intubation, ability to intubate without manipulation of the head or neck, and the apparently few complications, make it particularly attractive to emergency personnel. We conclude that guided orotracheal intubation using a lighted stylet is an effective and safe method of emergency intubation, even in the adverse prehospital environment.

Reappraisal of Mouth-to-Mouth Ventilation During Bystander-Initiated CPR

To the Editor: The “reappraisal” of the literature on mouth-to-mouth ventilation during bystander-initiated CPR, by a working group of the Basic Life Support and Pediatric Life Support subcommittees of the American Heart Association (AHA),1 is misleading and incomplete. There is no convincing evidence that the low incidence of initiation of CPR out of hospital by lay bystanders is the result of fear of becoming infected by mouth-to-mouth ventilation. Such fear should not be promoted. If such fear exists, however, it should be mitigated by explaining that initiating CPR is safe and by carrying a pocket-size barrier for ventilation of strangers. The errors in this article concerning behavioral, educational, epidemiological, and logistics issues will be summarized in a separate letter by Braslow and Brennan. Although the article says “… it is not intended to change any current AHA recommendations,” its publication has created confusion and the erroneous impression for laypersons and the media that in sudden coma, bystanders will save lives by merely pushing on the sternum (step C, circulation support). In cardiac arrest, oxygenated blood must be circulated to restore heartbeat and to keep the brain viable, requiring “head tilt plus blowing plus pumping.” The article suggests that mouth-to-mouth ventilation can be omitted in various forms of sudden loss of consciousness.1 Laypersons cannot differentiate between various forms of sudden coma and between the absence versus presence of a weak pulse. Coma always results in upper airway obstruction if the neck is flexed (references 26 to 31 in the article by Becker et al),2 3 4 5 6 as experienced by anesthesiologists every day. There are 20 million general anesthesias given in the United States each year. The data in Figure 1 are misleading1 because Gordon’s measurements of 1950 (reference 24 in the article by Becker et …

Reappraisal of mouth-to-mouth ventilation.

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Succinylcholine induced hyperkalaemia in patients with strabismus.

RésuméChez 20 malades soumis à la chirurgie pour correction de strabisme, nous avons mesuré les taux de potassium sérique. Chez sept malades, après induction au protoxide d’azote/halothane, nous avons donné du chlorure de succinylcholine. Les treize autres malades ont été intubés sous anesthésie au protoxide d’azote/halothane seulement. Nous avons observé une légère mais significative élévation du potassium sérique chez les malades du groupe qui avait reçu de la succinylcholine alors que nous n’avons pas observé de changement chez les malades de l’autre groupe. Les auteurs en viennent à la conclusion qu’une seule dose de succinylcholine par voie endoveineuse, selon toute évidence, n’entraine pas chez les porteurs de strabisme, une hyperkalémie dangereuse.

Cardiopulmonary Resuscitation (CPR) Basic and Advanced Life Support (BLS, ALS) Self-Training Systems (STS) for Paramedical and Medical Personnel

Resuscitation and acute respiratory care must be taught to all personnel involved in the management of everyday emergencies and mass casualties. Personnel range from the lay public to physician specialists. In deciding who should be taught what and how one must consider the limitations of learning ability of trainees and of resources. Mouth-to-mouth ventilation can be learned by laymen merely from viewing pictures, but better with manikin practice to perfection. CPR steps A-B-C can be effectively taught to non-physicians including laymen with instructor-coached manikin practice to perfection. but also with self-practice coached by audiotape, and to some extent even by frequent film viewing only without manikin practice. In 1972, A. Laerdal invented a CPR steps A-B-C self-training system consisting of a recording manikin, flipcharts and the coaching audiotape. We added a demonstration film to be shown before manikin practice.