DL McGee, DA Wald, S Hichliffe (Albert Einstein Med Ctr, Philadelphia)
Helium-Oxygen Therapy in the Emergency Department
J Emerg Med 15: 291-296, 1997.
Introduction : Helium -a colorless, odorless, noninflammable, nontoxic, metabolically inert is and safe gas for use in most patients. The unique physical properties of helium gas help to promote greater and smoother gas flow, reduce airway resistance and diminish the work of breathing in selected patients.
Use in Emergency Department:
Helium does not interact with human metabolism and helium administration requires continuous pulse-oximetry and body temperature monitoring. Helium-oxygen administration should be used as a temporizing measure as it produces no cure of its own. It can be used in ED in the treatment of patients with airway obstruction chronic obstructive pulmonary disease, asthma and bronchoconstriction from other causes.
The article highlights the use of Helium-Oxygen cylinders in the ED in a concise yet precise manner. Its use warrants prospective, controlled clinical trials to document the extent of airflow improvement and if its use has effects on the outcomes such as intubation or hospital admission.
G Nath, M Sekar (Christian Med College Hosp, Vellore, India)
Predicting Difficult Intubation: A Comprehensive Scoring System
Anaesth Intensive Care 25: 482-486, 1997
Difficulty in airway management is a major cause of anaesthetic morbidity and mortality. Hence, these patients would be valuable to anesthesiologists. The scoring system applied by the authors is :
TYPE VARIABLE SCORE
I Receding chin or TMD < 7cm 3 points
II Mallampati’s sign (uvular not visible) 2 points
III Restricted head extension 2 points
IV Protruding teeth 2 points
V Mouth opening < 4cm 2 points
VI Vertical neck length < 7.5cm 1 point
VII Neck circumference > 33cm 1 point
The study revealed that a score of 6 or more correctly identified 22 out of 23 difficult intubation patients, with 50 false positives, for a sensitivity of 96%, a specificity of 82%, and a positive predictive value of 31%.
The information provided in this article will be of immense value to the anaesthetists in planned elective intubations. However, the emergency physicians are not provided with this luxury.
F Adnet, RK Cydulka, C Lapandry (Univ Paris XIII, Bobigny, France; Case Western Reserve Univ, Cleveland, Ohio)
Emergency Tracheal Intubation of Patients Lying Supine on the Ground; Influence of Operator Body Position.
Can J Anaesth 45: 266-269, 1998.
Emergency intubation especially in the prehosptial setting is more difficult than in the operating room. This difficulty is further increased if the patient is lying supine on the floor. In the prospective study presented, the left lateral operator position was found to be more comfortable and resulted in a higher number of successful intubations than the kneeling down position. The authors have reported a lower incidence of Laryngoscopic difficulty (Cormack grade III or IV) as well as lower frequency of using external laryngeal pressure in the left lateral decubitus group.
These better results can be explained on:-
1) better visual axis for the operator with the patients’ tracheal axis.
2) Resting the left elbow on the ground and levering the forearm is an additional benefit.
Thus the left lateral decubitus posture seems to have real merit and should be recommended to all emergency medical services providers.
RB Palmer, DS Mautz, K Cox, et al (Univ of Washington, Seattle; Pudget Sound VA Med Ctr, Seattle)
Endotracheal Flumazenil: A New Route of Administration for Benzodiazepine Antagonism.
Am J Emerg Med 16: 170-172, 1998.
Intravenous flumazenil is administered for acute treatment of benzodiazepine intoxication. Often due to overdose leading to a circulatory collapse, it is not possible or may take too long to achieve a venous access. The authors have attempted endotracheal Flumazenil via the endotracheal route following a circulatory collapse. They have had good results, having achieved an average peak plasma flumazenil concentration of 65.9 mg/ml within 1 minute of administration.
However, the authors should preferrably have divided the subjects into 2 distinct groups – one group forming the control group and the other being the study group.
A comparative study is preferrable. They have proven only that Flumazenil is a safe and effective route especially in patients in whom intravenous access cannot be achieved.