Difficult airway management and the novice physician

From the Journal of Emergencies, Shock and Trauma:

Background: Selection of the ideal airway device in patients with difficult airways (DA) or potentially difficult airways remains controversial, especially, for a novice anesthesia physician (NP) who must deviate from conventional direct laryngoscopy with a rigid laryngoscope following a failed intubation and employ one of the several alternative devices. The author determines and compares tracheal intubation success rates, times to success and complications of a novice physician using four alternative airway devices in 20 obese (BMI more than 27.5) patients who may be more difficult to intubate than normal weight patients.

Materials and Methods: In this prospective randomized experimental study the author investigates a novice physician’s use of the Bullard™, Fiberoptic™, Fastrach™and Trachlight™ comparing reliability, rapidity and safety of orotracheal intubations. Following induction of anesthesia the NP was allowed up to a maximum of two attempts per device at oral intubation. Mean intubation times plus/minus SD, per cent success rates and postoperative complications were evaluated for each device. Results: The Fastrach™ was successful 100% of the time on the first attempt requiring a mean time of 55 seconds plus/minus 6.6. All intubations were unsuccessful following two attempts with the Fiberoptic™. A success rate of 20% (one of five) was achieved with the Trachlight™ on first attempt after 95 seconds. The Bullard™ was successful in 40 % (two of five) of the patients after a mean time 60 seconds plus/minus five, but was the only device to result in mild oral discomfort one day post operatively.

Conclusions: In the hands of a novice physician managing a difficult or potentially difficult airway, often encountered in obese patients, the Fastrach™ demonstrated the highest success rate.

Prehospital stroke care: potential, pitfalls, and future

From Current Opinion in Neurology:

Purpose of review: Tissue-type plasminogen activator is the only pharmacological treatment approved for acute ischemic strokes but is administered to less than 5% of the patients. Excessive prehospital and in-hospital delays and lack of stroke center coverage are major issues that negatively impact stroke care. New strategies are being developed and evaluated to increase the number of tissue-type plasminogen activator-treated patients.

Recent findings: Factors that limit rapid access to acute stroke care are discussed, including those influencing time intervals from stroke onset to hospital admission. We also describe strategies that hold promise to reduce prehospital delays and increase access to acute stroke treatment.

Summary: The shortening of prehospital delays requires education of patients and health professionals and optimization of transport strategies. Future developments may include video conferencing offering telestroke expertise, strategies (i.e. therapeutic interventions) that might help to treat acute stroke patients with tissue-type plasminogen activator, and prehospital selection of candidates for endovascular therapies.

The Perfect Storm

From the EM Blog:

Every two and a half years the equivalent of the entire US population will visit the ED. It may not be you, but Aunt Millie will come twice. We know you are coming, we just don’t know who you are. According to the CDC patients over 65 years of age are the fastest growing subset of patients utilizing ED services. They are sicker and their care is more complex. See Peter Sprivulis graph below depicting the complexity of acute health care needs as we age.