title: Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm.
abstract: BACKGROUND
  Difficult intubation management algorithms have proven efficacy in operating rooms but have rarely been assessed in a prehospital emergency setting. We undertook a prospective evaluation of a simple prehospital difficult intubation algorithm.
  
  
  METHODS
  All of our prehospital emergency physicians and nurse anesthetists were asked to adhere to a simple algorithm in all cases of impossible laryngoscope-assisted tracheal intubation. They received a short refresher course and training in the use of the gum elastic bougie (GEB) and the intubating laryngeal mask airway (ILMA), which were techniques to be used as a first and a second step, respectively. In cases of difficult ventilation with arterial desaturation, IMLA was to be used first. Cricothyroidotomy was the ultimate rescue technique when ventilation through ILMA failed. Patient characteristics, adherence to the algorithm, management efficacy, and early complications were recorded (August 2005-December 2009).
  
  
  RESULTS
  An alternative technique to secure the airway was needed in 160 of 2,674 (6%) patients undergoing intubation. Three instances of nonadherence to the algorithm were recorded. GEB was used first in 152 patients and was successful in 115. ILMA was used first in 8 patients and second in the 37 GEB-assisted intubation failures. Forty-five patients were successfully mask-ventilated, and 42 were blindly intubated before reaching the hospital. Cricothyroidotomy was used successfully in a patient with severe upper airway obstruction as a result of pharyngeal neoplasia. Early intubation-related complications occurred in 52% difficult cases.
  
  
  CONCLUSIONS
  Adherence to a simple algorithm using GEB, ILMA, and cricothyroidotomy solved all difficult intubation cases occurring in a prehospital emergency setting.
authors.affiliation: CHU H Mondor, AP-HP, Créteil, France. xavier.combes@hmn.aphp.fr
authors.forename: Xavier
authors.initials: X
authors.lastname: Combes
authors.forename: Patricia
authors.initials: P
authors.lastname: Jabre
authors.forename: Alain
authors.initials: A
authors.lastname: Margenet
authors.forename: Jean Claude
authors.initials: JC
authors.lastname: Merle
authors.forename: Bertrand
authors.initials: B
authors.lastname: Leroux
authors.forename: Michel
authors.initials: M
authors.lastname: Dru
authors.forename: Eric
authors.initials: E
authors.lastname: Lecarpentier
authors.forename: Gilles
authors.initials: G
authors.lastname: Dhonneur
mesh_terms: D000328:Adult; D000368:Aged; D000402:Airway Obstruction / Q000628:therapy*; D000465:Algorithms; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005602:France; D006801:Humans; D017214:Laryngeal Masks; D007828:Laryngoscopy / Q000379:methods*; D008875:Middle Aged; D011446:Prospective Studies