Glydescope vs laryngoscope in trauma

[pbruss]

the follow article was sent to me by a collegue, take a look ans let me know what you think.

when i read articles i cover 2 things:

1. do i believe their conclusion? habe they presented enough evidence to convience me that their findings are valid.
2. will this affect my practice?

Attachments:

Effect-of-video-laryngoscopy-on-trauma-pati....pdf (816.76 KB)

[kemple]

Very interesting study. I think a large part is operator comfort. You should use what you're most comfortable with but know how to use something else decently well as a backup IMO.

[DD]

These people need to play more x-box if they are going hypoxic with a glide.

[slevittMD]

I'm going to have to agree with Kemple...you should use whichever device you're more comfortable with. I don't think that one single-center study (even if it is Shock Trauma), particularly one which did not show any difference in the primary end point, would change my practice. If the patient looks like they're going to be an easy tube, I'd probably use DL. If they're obese or otherwise a difficult airway, I'd go with the glidescope. I also prefer the glidescope in trauma because you don't need to manipulate their head or neck as much, and these patients are obviously pretty much always in collars. Next, although the study didn't look at it, I think you get less trauma to the airway by using a glidescope. Finally, I agree with DD that maybe the people need more training with the glidescope if they're getting increased desats. I've found that typically when people are not successful with the glidescope, it's because they can't get the tube in the airway. These same people typically also don't know that the glidescope stylette is designed to be popped up with your thumb, which puts the tip of the ET tube more anterior and makes getting it in the airway easier.

I find the glidescope to be very easy to use and I rarely have trouble getting the tube in. However, I can see where people who are not coordinated, likely due to lack of adequate video game exposure, would have difficulty manipulating the tube into place. In contrast, when you use DL, it's typically a pretty straight shot into the airway.

[pbruss]

after reading this paper:

1. i do not agree with the conclusion. they did not present me with enough evidence to agee with the conclusion.
2. so it will not change my practice.

i think its an interesting question but if you go through the methods section there a few things that caught me eye.

1. they excluded any patient who died in the ER. for me, i would like to see if there is any greater chance my patient will die in my er if i reach for the glydescope or not.
2. they allowed the attending physician to throw a patient out of the study if they felt like it. how many attending do you know who would do that if there was any little complication, because i know A LOT who would.
3. the glydescope had only been used at this hospital for 2 years. they do say that the majority of intubation were tried my a PGY1 first but there is nothing about if they had been trained with it or if the attending had. they say it had been in use but i am sure every attending you have worked with wants you to use something different to intubate. some say go right with the glydescope some say nat to use glydescope first and keep it old school. who nows some of the intubations in this study that were randomized to the glydescope could have been the first time that doc had used it.
4. they used differnt induction agents (thiopental or etomidate)and again the use or adjustment of the meds was up to the discretion of the attending "either the thiopental was
Yeatts et al.
adjusted based on provider selection or etomidate was used in the range of 0.2 mg/kg to 0.4 mg/kg." there is no mention of induction drug choice or dosage difference between the 2 main groups and thiopental has known relatively immediate side effect of dropping the BP when used for induction (see bellow)
5. if you look at table 3 that compares the 2 main groups the mean time it took in seconds for intubation is listed but this information was missing from 20% of the cases. i think that a pretty important number not have available for analysis.

take a good look at table 2. the one thing i found interesting, and kind of funny was the data on who did the intubation and how sucessfull they were which confirms that we are the best when it comes to a nasty emergent airway, and that attending suck (66%) sucess on first attempt. so next time an attending pushes you out of the way for air way tell him you are 34% ready to get it if they miss.



Anesth Analg. 2005 Sep;101(3):622-8, table of contents.
Predictors of hypotension after induction of general anesthesia.
Reich DL1, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA.
Author information

Abstract
Hypotension after induction of general anesthesia is a common event. In the current investigation, we sought to identify the predictors of clinically significant hypotension after the induction of general anesthesia. Computerized anesthesia records of 4096 patients undergoing general anesthesia were queried for arterial blood pressure (BP), demographic information, preoperative drug history, and anesthetic induction regimen. The median BP was determined preinduction and for 0-5 and 5-10 min postinduction of anesthesia. Hypotension was defined as either: mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP <60 mm Hg. Overall, 9% of patients experienced severe hypotension 0-10 min postinduction of general anesthesia. Hypotension was more prevalent in the second half of the 0-10 min interval after anesthetic induction (P < 0.001). In 2406 patients with retrievable outcome data, prolonged postoperative stay and/or death was more common in patients with versus those without postinduction hypotension (13.3% and 8.6%, respectively, multivariate P < 0.02). Statistically significant multivariate predictors of hypotension 0-10 min after anesthetic induction included: ASA III-V, baseline MAP <70 mm Hg, age > or =50 yr, the use of propofol for induction of anesthesia, and increasing induction dosage of fentanyl. Smaller doses of propofol, etomidate, and thiopental were not associated with less hypotension. To avoid severe hypotension, alternatives to propofol anesthetic induction (e.g., etomidate) should be considered in patients older than 50 yr of age with ASA physical status > or =3. We conclude that it is advisable to avoid propofol induction in patients who present with baseline MAP <70 mm Hg.

[kemple]

Great analysis of the study Dr. Bruss, thanks.

[gigantor]

Great talk in EMRap last month, bottom line was "resuscitate before u intubate." Keep a nasal cannula on at 15 LPM to add PEEP while u bag to help ventilate while u address the BP. Consider push dose press or if needed too. All that, and ketamine.

[pbruss]

What to you all believe about ketamne and elevated ICP?

[kemple]

Most recent studies show it doesn't have much effect on ICP at all and should be considered safe. Either way I like Etomidate so I have no problem with that in head injury.

[slevittMD]

lifeinthefastlane.com/education/ccc/ketamine-rsi-for-head-injury/

Great review of the current literature, showing that ketamine is not harmful, may even be helpful. I'm a big fan of ketamine for most everything! It's one of the safest drugs for RSI, can quickly put down a violent patient without an IV, great analgesic, good for asthmatics, doesn't need to be carefully titrated for sedations, etc etc.

[DD]

I would hate to see a guy like Bruss or Womack with an emergence reaction though...

[pbruss]

been having one for the past 32 years

[DD]

Jul 19, 2014 23:46:52 GMT -5 pbruss said:

been having one for the past 32 years


lol