Laryngoscopic views during rapid sequence intubation in the emergency department

Abstract

Objectives: Our objective was to document and compare the views obtained at laryngoscopy during emergency department (ED) rapid sequence intubation (RSI) by anesthetists and emergency physicians of varying seniority and experience. Methods: Data were prospectively collected on every intubation attempt in 7 urban Scottish EDs for 2 calendar years, commencing Jan. 11, 1999. Data included patient's age, gender, grade and specialty of intubator, laryngoscopic grade, and number of intubation attempts. Quality of laryngoscopic visualization was graded using the Cormack-Lehane scale, with grades I and II considered good visualization. A descriptive analysis was performed, and key statistical comparisons made. Results: During the study period, 735 patients underwent RSI, and grade of intubation was documented in 672 cases (91%). In total, 68.2%, 23.4%, 6.1% and 2.4% of the intubations were classified as Cormack-Lehane grade I, II, III and IV respectively. Overall, anesthetists and anesthesia trainees achieved good laryngoscopic visualization in 94.0% of cases (95% confidence interval [CI], 90.8%-96.4%) and emergency physicians and emergency medicine trainees did so in 89.2% of cases (95% CI, 85.5%-92.3%; p = 0.027). Specialist registrars and senior house officers in anesthesia were more likely to obtain good visualization than their emergency medicine counterparts (p = 0.034 and 0.035 respectively). Consultants in emergency medicine were more likely to obtain good views than their anesthesia counterparts, but this difference was not statistically significant. Conclusions: Anesthetic trainees obtain better laryngoscopic views than emergency medicine trainees, but these differences disappear with increasing emergency physician seniority, suggesting a training and experience effect. Emergency medicine trainees may benefit from additional focus on laryngoscopic visualization techniques early in their training period. EM ADVANCES • INNOVATIONS EN MU

Assessment of Movement Patterns during Intubation between Novice and Experienced Providers Using Mobile Sensors: A Preliminary, Proof of Concept Study

“…In a multicenter analysis including over 6,000 ETIs, the first attempt success rates varied by provider experience with the first year emergency medicine residents having success rate of only 72% compared to 82% and 88% in the second year and third year, respectively [ 17 ]. First attempt success also decreases with Cormack-Lehane view where grade 3 views have first attempt success rates near 40%, similar to those noted in our study [ 16 ]. Complications occur more frequently in cases where multiple ETI attempts are made [ 3 ].…”

“…We felt a difficult airway (Cormack-Lehane grade 3) would allow for greater discrimination between the movement patterns of novice and experienced providers. As Cormack-Lehane grade 3 views are infrequently encountered in emergency airway management, we focused our efforts on the cadaver model [ 14 – 16 ]. Also, from a patient safety and research ethics standpoints, we did not feel it was in patients' best interest to perform multiple intubation attempts on a patient or patients with a difficult airway, especially with novice providers, for a proof of concept study.…”

Tracheal intubation in the emergency department: the Scottish district hospital perspective

“…[17][18][19] It is clear from our results that the intubation is most likely to be successful on the first attempt regardless of specialty, and successful intubation on the first attempt should be the aim of every ED intubation attempt.…”

Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge

“…Graham et al also reported that anesthetic trainees obtained better laryngoscopic views than Emergency Medicine trainees, but these differences disappeared with increasing Emergency Physician seniority (19). Furthermore, Kelly et al suggested that the seniority of Emergency Physicians likely reduced the rate of unscheduled return visits (6).…”