Auckland HEMS video laryngoscopy trial

By Dr James LeFevre

Auckland HEMS is currently trialling the Storz C-MAC Videolaryngoscope (VL), and we are also aiming to trial this device in the Auckland Adult Emergency Department soon.

https://i0.wp.com/www.carolinashealthcare.org/images/CMC/Storz-Video-LaryngoscopeMd.jpg

There is much debate in the FOAMEd community regarding the place of the VL in Emergency airway management, with often quite polarised views, and the published literature is yet to catch up with the uptake of the various multitude of VL devices.

There are many different Videolaryngoscopes out there, but they generally boil down to two basic types:

Those that use hyperangulated blades to “see around the corner” (such as the Glidescope that is currently available in Auckland ED), and those that use Macintosh-style blades that are connected to a video screen (Such as the Storz C-MAC).

Hyperangulated VL blades often allow superb laryngeal visualisation, with the downside that tube delivery requires a different technique with an angulated stylet, whereas Macintosh-style blades allow for the use of the same tube delivery technique through direct laryngoscopy (looking directly at the larynx) or indirect laryngoscopy (looking at the screen to see the larynx).

Although the literature is still not clear on this issue, it would appear that some patients are more easily intubated with direct laryngoscopy with a standard blade, and others are more easily intubated with a hyperangulated blade, so intuitively it makes sense to have both options available.

The C-MAC we are trialling has a Mac-3, Mac-4, and a hyperangulated D-Blade option. Potential advantages include the ability to turn the screen away from the airway operator whilst using the Mac blade to allow teaching and the resuscitation team to see what sort of actual view is being obtained (sometimes this info just ain’t forthcoming in real time!), allow assistants other than the airway operator to perform suction under visualisation, and has a hyperangulated blade should a poor view be obtained with a standard Mac blade.

Attached below are some FOAM links which discuss the differences between VL and DL, how intubation techniques differ, and some of the pros and cons to each technique. There is also some published literature in the password protected section, happy reading.

Lifeinthefastlane.com on Videolaryngoscopy at:

http://lifeinthefastlane.com/education/ccc/direct-versus-video-laryngoscopy/

http://lifeinthefastlane.com/education/ccc/video-laryngoscopy/

PHARM (Prehospital and Retrieval Medicine) at:

http://prehospitalmed.com/2012/09/07/why-video-will-never-kill-the-direct-laryngoscope-star/

EMCRIT Scott Weingart versus Paul Mayo Debate – Direct versus Video laryngoscopy at:

http://emcrit.org/podcasts/has-video-laryngoscopy-killed-the-dl-star/

Richard Levitan at:

http://www.epmonthly.com/subspecialties/technology/video–direct-laryngoscopy-/

http://www.epmonthly.com/features/current-features/four-secrets-to-video-laryngoscopy-/

Relevant literature:

A Comparison of the C-MAC Video Laryngoscope
to the Macintosh Direct Laryngoscope for Intubation in the Emergency
Department

The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study

Comparison of video laryngoscopy and direct laryngoscopy in a critical care transport service

Assessing the efficacy of video versus direct laryngoscopy through retrospective comparison of 436 emergency intubation cases

A systematic review of the role of videolaryngoscopy in successful orotracheal intubation

Glidescope video-laryngoscopy versus direct laryngoscopy for
endotracheal intubation: a systematic review and meta-analysis

Effect of video laryngoscopy on trauma patient survival: A
randomized controlled trial

Variables associated with successful intubation attempts using video laryngoscopy: a preliminary report in a helicopter emergency medical service

Click HERE for full text version of the articles above (secure area limited to ADHB staff)

Trauma airway in prehospital and retrieval medicine – Minh Le Cong

This presentation is from the ANZCA Airway Management and Trauma Special Interest Group Meeting in June 2013. It is delivered by Minh Le Cong (RFDS medical officer, Assistant Professor in Retrieval Medicine, and the world’s most ardent advocate for ketamine..)

If you haven’t already checked out Minh’s superb prehospital website, click HERE

The Vortex

A recent concept that has been widely discussed on FOAM sites, as well as at the SMACC  conference, is The Vortex (pdf) 

Who needs an algorithm? Here is The Vortex!

Who needs an algorithm? Here is The Vortex!

The Vortex is a simple cognitive aid that can be used in the setting of an unanticipated difficult airway. Conceived by Nicholas Chrimes (Melbourne anaesthetist) and Peter Fritz (Melbourne emergency physician), it aims to simply concepts, move away from complex algorithims, and be applicable in multiple settings.

Key to the concept is that the key goal in an unexpected difficult airway situation is alveolar oxygen delivery. Techniques to deliver oxygen (LMA, ETT, face mask) are regarded as equivalent, as any of these, if successful, will move a desaturating patient out of the Vortex into the ‘green zone’ where oxygenation is adequate for a ‘time out’ and alternative planning to occur. At the centre of the vortex is a surgical airway.

Resources regarding The Vortex:

Discussion page and podcast from Minh Le Cong, with an interview of the creators of The Vortex

Presentation by Nicholas Chrimes:

The Vortex in action: