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MSM Podcast Ep 003 DL and VL Show Notes

In EMS medicine, the debate has begun as to whether we should use direct laryngoscopy or video laryngoscopy to secure our patient’s airways. As with many things in emerging data, the evidence is inconclusive, but is ever progressing. To begin, we must think about how good we are at intubating and securing airways in the field.

In 2015, a study from the Netherlands looked at whether paramedics were equal or superior to ED physicians when attempting to secure the airway with an endotracheal tube. Specifically, the practitioners that were involved were helicopter physicians, and they were directly compared to road paramedics. Depressingly, first pass intubation was almost twice as successful when a physician attempted the to secure the airway (84.5% vs. 46.4%)[1]. So, perhaps the problem is simply that paramedics either A) are not that good at intubating or B) Don’t have enough practice. The real answer might be a mix of the two.

A 2017 meta analysis from Australia found that the average first pass intubation rate was approximately 84%[2]. This differs slightly from a 2011 study that showed first-pass success was 77% in the United States. This included all patients in the ED, whether the patient presented with a medical or trauma complaint. Given this patient population, we can use 84% as a reasonable benchmark for first-pass success. Of course, its difficult to obtain reliable data on first-pass success in the field, since there are differing opinions as to what “first-pass” means. But what we can look at is how first-pass success increased after the introduction of video laryngoscopy. A Japanese study showed a 6% increase in first-pass success rate when they introduced VL, and once the VL was introduced in the study, use of the video laryngoscope as an initial intubation method increased 25%, and the use of VL as the primary tool of intubation increased from 2% to 40%[3]. Additionally, a 2016 study in Annals showed that use of a C-MAC VL had an 18% higher first pass rate, and had 28% higher first pass success without hypoxemia[4]. However, despite all of this, there are still numerous studies and data sets that do not support using VL as a front-line intubation tool, or at least do not show that VL is superior to DL. In the end, the jury is still largely out. However, it would probably be advisable to use what you are comfortable with. If you work well with DL, stick to it. If VL is your thing, use that.

Paper of the Week

Rech, et al. When to pick the Nose: Out-of Hospital and Emergency Department Intranasal Administration of Medications. Annals of Emergency Medicine in Press 2017 http://dx.doi.org/10.1016/j.annemergmed.2017.02.015

Med Box

EMS Week occurs this year from May 21-27. EMS week was started by President Ford to occur annually during the third year of May. The purpose of EMS week is to celebrate the important work and essential function performed by EMS workers.

 

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[1] Joost et al. First-pass intubation success rate during rapid sequence induction of prehospital anaesthesia by physicians versus paramedics

 

European J. Emerg. Med. Dec. 2015 22:6 p. 391-394

[2] Park L et al. Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care.Emerg. Med. Autralasia 2017 Feb;29(1):40-47

[3] Goto Y et al. Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010-2016. Resuscitation 2017 May; 114:14. (http://dx.doi.org/10.1016/j.resuscitation.2017.02.009)

[4] Dodd et al. Use of the C-MAC Yields High Rates of Endotracheal Intubation First-Pass Success and First-Pass Success Without Hypoxemia Whether the Intubator Views the Video Screen or Not Annals of Emerg. Med. 68:4S Oct. 2016