Prehospital Emergency Cricothyrotomy in Dogs Part 1: Experiences With Commercial Cricothyrotomy Kits

The surgical cricothyrotomy (CTT) has been recommended for emergency front of neck airway access (eFONA) during a cannot intubate, cannot oxygenate scenario for military working dogs (MWD) and civilian law enforcement working dogs (operational K9s). In prehospital and austere environments, combat medics and emergency medical service providers are expected to administer emergency medical care to working dogs and may only have emergency airway kits designed for humans at their disposal. The objective of this article is to provide a detailed description of the application of such devices in cadaver dogs and highlight potential alterations to manufacturer guidelines required for successful tube placement. The kits evaluated included the Portex® PCK, Melker universal cricothyrotomy kit and H&H® emergency cricothyrotomy kit. A novel technique for awake cricothyrotomy in the dog is also described, which can also be considered for in-hospital use, together with the open surgical method described for the H&H® kit. To the authors' knowledge, this is the first publication documenting and providing instruction on the application of commercial cricothyrotomy kits in dogs.

Tension Pneumothorax After Emergency Intubation: a Case Report and Review of the Literature

Introduction:Tension pneumothorax during the emergency airway is a rare but deleterious event, which may cause severe cardiorespiratory collapse, leading to brain damage or even death.Case presentation: A 34-year-old male patient was admitted with sudden chest pain. He was diagnosed with acute myocardial infarction and his chest X‑ray did not show pneumothorax. The patient after intubation presents emergent complications and was gave treatment.Discussion and Conclusions: Tension pneumothorax in tracheal intubation of emergency is a more rare but deleterious event, especially when predisposing factors cannot be known in view of acute profound hypoxemia. We collect several rare cases of tension pneumothorax of different etiology and drawing lessons from the past.

974 Improving Safety for Tracheostomy and Laryngectomy Patients Within A Regional Head and Neck Unit

Aim To improve the safety of tracheostomy and laryngectomy patients within a UK-based regional head and neck unit. Method This audit was conducted against standards taken from the National Tracheostomy Safety Project (NTSP). Inclusion criteria were all patients with a tracheostomy or laryngectomy on the ward, there were no exclusion criteria. Data was collected per inpatient episode for a one month period pre- and post- implementation of each intervention (1st March to 31st May 2020). Results Pre-intervention results showed that none of the 19 neck-breathing inpatients during March 2020 had a bedhead sign or emergency algorithm displayed, however all patients had required bedside equipment and the only unavailable ward equipment was capnography. Laminated bedhead signs and algorithms were implemented and 33% neck-breathing patients had signs displayed during April 2020. Further intervention in May 2020 to educate ward staff led to 90% of patients having a bedhead sign displayed and 80% having an algorithm displayed. Conclusions Overall, our unit has very high standards of care for neck-breathing patients. The use of bedhead signs and emergency airway algorithms is an integral part of providing safe care for neck-breathing patients and all members of staff are responsible for their use. The COVID-19 crisis has impacted on the number of elective procedures being performed which has impacted upon the numbers for the post-intervention arms of our audit. Reduced staffing due to sickness during the pandemic may have contributed to the substandard results.

Prospective observational study of the endotracheal intubation complications in Emergency Department

Endotracheal intubation is the gold standard intervention for emergency airway management. Complications related to endotracheal intubation are numerous and frequent. Complications were identified as being related to endotracheal intubation in our study: hypoxia, hypotension, dysrhythmia, cardiac arrest, hypertension, tachycardia, bradycardia, regurgitation and aspiration of stomach contents, endobronchial intubation, and incorrect positioning of the endotracheal tube in either the esophagus or hypopharynx. The study included 186 patients that were over 18 and intubated. The complication rate associated with endotracheal intubation was found to be over 50%. Patients included in our prospective, observational study were all initially evaluated in our ED. A survey was filled out at a time as soon as possible after intubation to record the personnel in charge of intubation, details of the procedure, and hemodynamic changes and complications. Our study found that the following factors were associated with increased rates of complication in intubated patients: history of acute renal failure, history of cancer, GCS < 8, midazolam use during intubation, history of trauma, crash intubation, history of shock, history of cardiac arrest, resident with <1 year of experience carrying out the intubation, residents with 2+ years of experience and specialists carrying out the intubation, history of respiratory failure, and patient age <65. To better understand which patients were likely to be affected by complications associated with intubation, as well as to understand which precautions to take, this study aims to investigate the aggravating factors and complication rates of endotracheal intubation.

A quantitative evaluation of aerosol generation during manual facemask ventilation

SummaryManual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol generating procedure. This designation is based on a single epidemiological study suggesting an association between facemask ventilation and transmission from the SARS 2003 outbreak. There is no direct evidence to indicate whether facemask ventilation is a high-risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation, and facemask ventilation with an intentionally generated leak, in anaesthetised patients with neuromuscular blockade. Recordings were made in ultraclean theatres and compared against the aerosol generated by the patient’s own tidal breathing and coughs. Respiratory aerosol from tidal breathing was reliably detected above the very low background particle concentrations (191 (77-486 [3.8-1313]) versus 2.1 (0.7-4.6 [0-12.9] particles.l-1 median(IQR)[range], n=11, p=0.002). The average aerosol concentration detected during facemask ventilation both without a leak (3.0 particles.l-1 (0 – 9 [0-43])) and with an intentional leak (11 particles.l-1 (7.0 – 26 [1-62])) was 64-fold and 17-fold lower than that of tidal breathing (p=0.001 and p=0.002 respectively). The peak particle concentration during facemask ventilation both without a leak (60 particles.l-1 (0 – 60 [0-120])) and with a leak (120 particles.l-1 (60 – 180 [60-480]) were respectively 20-fold and 10-fold lower than a cough (1260 particles (800 – 3242 [100-3682]), p=0.002 and p=0.001 respectively). This study demonstrates that facemask ventilation, even performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, facemask ventilation should not be considered an aerosol generating procedure.