title: Establishing a definitive airway in the trauma patient by novice intubators: A randomised crossover simulation study.
abstract: BACKGROUND
  Establishing a definitive airway, defined as a tube placed in the trachea with cuff inflated below the vocal cords, is standard of care in pre-hospital airway management of the trauma patient. However, in this setting, and using manual in-line stabilisation of the neck, success rate of intubation by inexperience providers is suboptimal. The use of supraglottic airway devices that allow blind tracheal intubation has been suggested as an alternative method by the Advanced Trauma Life Support (ATLS) programme of the American College of Surgeons. We aimed to compare intubation with the standard intubation technique (direct laryngoscopy [DL]) with blind intubation through an intubating-laryngeal mask airway (I-LMA) during manual in-line stabilisation of the neck.
  
  
  METHODS
  A randomised, crossover manikin study was performed with 29 emergency medical technicians undergoing training for paramedic status. Outcome measures were success rate in one intubation attempt, duration of intubation, and assessment of ease-of-use.
  
  
  RESULTS
  Study subjects had a higher success rate of tracheal intubation with I-LMA than with DL (27/29 vs. 18/29, p<0.025), and I-LMA was assessed as easier to use (4 vs. 3, p<0.0001). Longer duration of intubation was found with I-LMA compared to DL (54.2 vs. 42.8s, p<0.002). Success rate of correct placement of I-LMA within the airway was 28/29 (96.5%). Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL (26.9 vs. 42.8s, p<0.0001).
  
  
  CONCLUSIONS
  Novice intubators had a higher success rate of intubation with I-LMA than with DL, but duration of intubation was longer with I-LMA. Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL. Findings of this simulation study suggest that in the presence of manual in-line stabilisation of the neck, I-LMA-guided intubation is the preferred technique for novice intubators.
authors.affiliation: Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel. Electronic address: itai@pem-database.org.
authors.forename: Itai
authors.initials: I
authors.lastname: Shavit
authors.affiliation: Surgery Department, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
authors.forename: Barak
authors.initials: B
authors.lastname: Levit
authors.affiliation: Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
authors.forename: Nofar Ben
authors.initials: NB
authors.lastname: Basat
authors.affiliation: Anesthesiology Department, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
authors.forename: Dekel
authors.initials: D
authors.lastname: Lait
authors.affiliation: Anesthesiology Department, Bnai Zion Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
authors.forename: Mostafa
authors.initials: M
authors.lastname: Somri
authors.affiliation: Anesthesiology Department, Bnai Zion Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
authors.forename: Luis
authors.initials: L
authors.lastname: Gaitini
mesh_terms: D018592:Cross-Over Studies; D004634:Emergency Medical Technicians / Q000193:education*; D004635:Emergency Medicine / Q000193:education*; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods; D007557:Israel; D017214:Laryngeal Masks; D007828:Laryngoscopy; D008348:Manikins; D008889:Military Personnel / Q000193:education*
keywords: Airway; Cervical spine; Injury; Intubation; Laryngeal mask; Laryngoscopy; Supraglottic; Trachea; Trauma