Acute airway management in the emergency department by non-anesthesiologists

Abstract

P Pu ur rp po os se e: : The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed.S So ou ur rc ce e: : A narrative review of the literature on the practice of airway management by non-anesthesiologists.P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by nonanesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor. C Co on nc cl lu us si io on ns s: : The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided. Objectif : La responsabilité de l'assistance respiratoire d'urgence revient souvent à des médecins non-anesthésiologistes. Les urgentistes utilisent maintenant de routine le bloc neuromusculaire pour faciliter l'intubation. La documentation à l'appui de cette pratique a été publiée presque exclusivement dans les journaux de médecine d'urgence (MU). Nous présentons l'ensemble de ces documents et exposons les questions de formation. Source : Une revue traditionnelle de la documentation sur la pratique de l'assistance respiratoire par des non-anesthésiologistes. Constatations principales : Une proportion significative de l'assistance respiratoire d'urgence, réalisée à l'extérieur de la salle d'opéra-tion, relève de non-anesthésiologistes. L'intubation en séquence rapide (ISR) est reconnue comme une intervention centrale dans le domaine de la MU. L'ISR est généralement réalisée par des urgentistes dans les grands centres. Le soutien anesthésiologique pour la pratique de l'ISR

Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial

“…For example, rapid sequence intubation has become the purview of emergency physicians who generally perform this procedure with a high degree of skill and success. 20,21 The objectives of training in internal medicine by the Royal College of Physicians and Surgeons of Canada list endotracheal intubation as a procedural skill under cardiopulmonary resuscitation. 22 Indeed, the 2010 American Heart Association Guidelines for Adult Advanced Cardiovascular Life Support (ACLS) states ''…ideally ACLS providers also should be trained and experienced in insertion of an advanced airway.''…”

Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability

“…This is intriguing as it is common practice for emergency physicians to use neuromuscular blocking medications, yet this practice remains a controversial issue in anesthesia practice. 38 Emergency physicians often use neuromuscular blocking medication to facilitate EETI, citing the fact that muscle relaxation allows for optimal intubation conditions. The mechanism for this association is unclear as neuromuscular blocking medications do not have a known effect on blood pressure.…”

L’intubation trachéale hors du bloc opératoire

“…11 The authors tell us that rapid sequence intubation, [(RSI), not induction] where the patient is anesthetized (with hypnotic agents and muscle relaxants) to facilitate tracheal intubation, is employed more and more by ER physicians. Used sparingly in the ER in the early 80's for cases of obtunded patients who required intubation but would not open their mouth, succinylcholine is now in common use and, in the ER, RSI has become the "norm" for intubating the patient's trachea in the absence of contraindication.…”

“…publié dans ce numéro du Journal, on peut prendre toute la mesure de la distance qui sépare l'attitude des anesthé-siologistes canadiens de celle qui prévaut dans la littérature émanant des urgentologues quant à la gestion de l'intubation trachéale des patients de l'urgence. 11 On y apprend que l'intubation (et non l'induction) en séquence rapide (ISR), où l'on anesthésie (avec agents hypnotiques et curares) le patient pour faciliter l'intubation trachéale est de plus en plus employée par les urgentologues. Utilisée parcimonieusement au début des années 80 dans les cas de patients obnubilés dont on ne pouvait ouvrir la bouche, la succinylcholine fait maintenant partie des moeurs à l'urgence et l'ISR y serait devenue la méthode «normale» d'intubation trachéale en l'absence de contre-indication.…”