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Category Archives: All Updates
Cuffed tracheal tubes for children
In a prospective randomised controlled multi-centre trial, cuffed tracheal tubes were compared with uncuffed tubes in 2246 children aged from birth to five years undergoing general anaesthesia. There was no significant difference in post-extubation stridor but the need for tube exchange was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001).
From the resuscitation point of view, there remain few if any arguments for using an uncuffed tube.
Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children
Br J Anaesth. 2009 Dec;103(6):867-73
Acute medicine guidelines
The Acute Medicine in the Emergency Department Seminar refers to a number of guidelines from different sources.
Go to the Acute Medicine guidelines
First Aid for Burns
A review of burn first aid treatments highlights the paucity of evidence on which to make firm recommendations. The authors recommend using cold running tap water (between 2 and 15 degrees C) and to avoid ice or alternative therapies. The optimum duration of first aid application and the delay after the injury for which first aid can still be effective are two areas of research which need further exploration.
A review of first aid treatments for burn injuries
Burns. 2009 Sep;35(6):768-75
Mallampati unhelpful in ED patients
A prospective study of 366 patients requiring intubation in the ED revealed by logistic regression analysis that the only component of the ‘LEMON’ classification* to be independently associated with difficult intubation was a thyroid-hyoid distance of less than 2 finger breadths. They conclude that Mallampati classification is not a useful tool in predicting difficult intubation in the ED and that the LEMON acrostic can be modified to “LEON.”
Determination of difficult intubation in the ED
Am J Emerg Med. 2009 Oct;27(8):905-10
*Further definition of LEMON and information on difficult airways are available in these presentation slides by Rob Vissers FACEP
Cricoid pressure during mask ventilation
While cricoid pressure’s effectiveness at preventing passive regurgitation and aspiration during intubation is disputed, it may be effectively applied during bag-mask ventilation to prevent gastric insufflation of air in both adults and children.
The prevention of gastric inflation–a neglected benefit of cricoid pressure
Anaesth Intensive Care. 1988 May;16(2):139-43
The effect of cricoid pressure on preventing gastric insufflation in infants and children
Anesthesiology. 1993 Apr;78(4):652-6
Cricoid pressure – ?not so useless after all
An interesting MRI-based study of adult volunteers takes a further look at whether cricoid pressure effectively occludes the digestive tract. The authors assert that the part of the digestive tract at the level of the cricoid is the distal hypopharynx, that it is fixed in relation to the airway (making the previously demonstrated lateral oesophageal displacement irrelevant), and that the lumen may be obliterated during Sellick’s manouevre.
Accompanying pro and con editorials reaffirm the need for further clinical evidence on the effectiveness of the technique.
Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant
Anesth Analg. 2009 Nov;109(5):1546-5
Physicians didn't improve outcome from nontraumatic cardiac arrest
A Norwegian study retrospectively compared outcomes from non-traumatic cardiac arrest between ambulances staffed by physicians (PMA) and non-physician ambulances (non-PMA). There were no differences in any of the clinical outcome measures used in this study of 977 patients, in which 13% (PMA) and 11% (non-PMA) survived to hospital discharge.
Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome
Resuscitation. 2009 Nov;80(11):1248-52
Fluids for cooling post cardiac arrest
Large volume cold fluid resuscitation after return of spontaneous circulation can contribute to effective cooling but does it impair cardiac or respiratory function? A retrospective review of 52 resuscitated cardiac arrest patients suggests that the infusion of large volumes of cold fluid does not cause a further significant reduction in respiratory function beyond that normally seen after cardiac arrest despite significantly reduced LV function.
Effects of large volume, ice-cold intravenous fluid infusion on respiratory function in cardiac arrest survivors
Resuscitation. 2009 Nov;80(11):1223-8
In the same issue of Resuscitation, a prospective study of cardiac arrest survivors in positive fluid balance from cold fluid cooling showed frequent evidence of hypovolaemia as determined by serial ultrasound assessment.
An accompanying editorial suggests this may be due to the systemic inflammatory response syndrome that follows successful cardiac arrest resuscitation; large volumes are tolerated well and myocardial dysfunction should not lead to restriction of fluids after cardiac arrest.
Assessment of intravascular volume by transthoracic echocardiography during therapeutic hypothermia and rewarming in cardiac arrest survivors
Resuscitation. 2009 Nov;80(11):1234-9
Paediatric gastric tubes
A child with status epilepticus has been stabilised and intubated and is awaiting admission to the paediatric intensive care unit. You decide to insert a nasogastric tube. The nurse asks the following questions:
1. What size gastric tube would you like?
[EXPAND Answer]A general guide is twice the size of the uncuffed tracheal tube.
A four year old for example would usually need a tracheal tube size of 5.0mm internal diameter (age/4 +4), so would need a 10 Fr gastric tube.
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2. To what length are you intending to insert it?
[EXPAND Answer]A formula based on height of the child can be used, so get your tape measure or length chart out:
For neonates < 2 weeks and children >8 years 4 months a method called NEMU (nose-ear-midxiphoid-umbilicus measurement) may be used.
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3. How will you confirm placement?
[EXPAND Answer]It is very likely this child will get a post-intubation chest radiograph and the gastric tube tip can be visualised on that. However non-radiological tests should be used and pH testing of the aspirate is recommended, looking for pH<6
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Further details on these measurements including positive and negative likelihood ratios of pH testing can be found in the evidence-based guideline from Cincinnati Children’s Hospital