Current Articles That Matter

Rinderknecht AS, Mittiga MR, Meinzen-Derr J, et al. Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data. Acad Emerg Med 2015; 22:431.

It may seem shocking, but this study found intubation of the esophagus does not improve oxygenation.  Seriously, the conclusions were that desaturation was more common if: respiratory indication for intubation, esophageal intubation, and duration > 30 seconds of laryngoscopy (both individual and cumulative).

Godwin SA et al. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med. 2014;63:247-258. Full Text Link

Conclusions: 1. Fasting is not required (Level B). 2. Capnography is helpful (Level B). 3. You don't need two physicians in the room, but your hospital may require it (Level C). 4. You can use pretty much any drug you want, specifically ketamine (A), propofol (A), "ketofol" (B), etomidate (B, C in kids), dexmedetomidine (no evidence), alfentanil (C), and remifentanil (no evidence) (Levels A-C).

Brown CA et al. Techniques, Success, and Adverse Events of Emergency Department Adult Intubations. Ann Emerg Med. 2015;65:363-370.

Emergency physician intubation is highly successful, 99.4%. Video laryngoscopy use and rocuronium vs. succinylcholine use have increased dramatically.

 

Landmark Articles

Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-75.e1.

Optimizing positioning, preoxygenation, PEEP, and passive apneic oxygenation are the keys to prevent desats.

Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, Ludwig TA. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885-91.

If you are fat, old, have a beard, and snore (i.e. you look like Santa Claus), modify the only risk factor you can and at least shave off your beard. "Body mass index of 30 kg/m or greater, a beard, Mallampati classification III or IV, age of 57 yr or older, severely limited jaw protrusion, and snoring were identified as independent predictors for grade 3 MV. Snoring and thyromental distance of less than 6 cm were independent predictors for grade 4 MV. Limited or severely limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and body mass index of 30 kg/m or greater were independent predictors of grade 3 or 4 MV and difficult intubation."

Orebaugh SL. Difficult airway management in the emergency department. J Emerg Med. 2002 Jan;22(1):31-48.