The Cormack-Lehane (C-L) grade III airway is considered to be a challenging airway to intubate and is associated with a poor intubation success rate. The purpose of this study was to investigate whether the holding position, shapes, bend angles of the endotracheal tube (ET) and the stylet-assisted lifting of the epiglottis could improve the success rate of intubation. Thirty-two participants, 26 physicians, 2 residents, and 4 nurse practitioners, with 12.09 ± 5.38 years of work experience in the emergency department and more than 150 annual intubation events, were enrolled in this randomized, cross-over mannequin study. We investigated the effects of straight-to-cuff ET shapes with 35° and 50° bend angles, banana-shaped ET with longitudinal distances of 28 cm and 26 cm, two methods of holding the ET (either on the top or in the middle), and lifting or not the epiglottis, on the intubation duration, its success rate, and its subjective difficulty. The aim of the study is to provide optimized intubation strategies for difficult airway with C-L IIb or III grades, when the inlet of the trachea cannot be visualized. The two groups that lifted the epiglottis using the stylets, in bend angles of 35° and 50°, had the shortest duration of intubation (23.75 ± 14.24 s and 20.72 ± 6.90 s, hazard ratios 1.54 and 1.85 with 95% confidence intervals [95% CI] of 1.01–2.34 and 1.23–2.78, respectively) and a 100% success rate in intubations. In the survival analysis, lifting of the epiglottis was the only significant factor (p < 0.0001, 95% CI 1.34–2.11) associated with the success rate of intubation. The use of the epiglottic lift as an adjunctive technique can facilitate the intubation and improve its success rate without increasing procedure difficulty, in C-L III airway, when only the epiglottis is seen. ClinicalTrials Registry ( https://clincaltrials.gov , identifier NCT03366311).

A 74-year-old male with chronic kidney disease presented to the emergency department with asystole. Mechanical chest compression was started immediately using a piston-type thumper device. The initial potassium level was 7.7 mEq/L and bedside point-of-care ultrasound (POCUS) revealed no pericardial fluid. With standard resuscitation and anti-hyperkalemia treatment, return of spontaneous circulation (ROSC) was achieved within 10 minutes of compressions. At 15 minutes post-ROSC, the patient went into pulseless electrical activity. A repeated POCUS discovered massive pericardial fluid suggesting the presence of cardiac tamponade. Bedside pericardiotomy was performed followed by open thoracotomy. Laceration of the right ventricular wall adjacent to the fracture site of sternum was found, implicating that it was the complication of mechanical chest compression. After surgical repair and intensive postoperative care, the patient survived with full conscious recovery at day 6 of admission. Our case emphasizes the importance of POCUS in resuscitation, especially when the patient's condition deteriorates unexpectedly. Copyright (C) 2018 The Emergency Medicine Association of Turkey. Production and hosting by Elsevier B.V. on behalf of the Owner.

Background: The management of contaminated airways potentially compromises the quality of cardiopulmonary resuscitation (CPR). Objectives: This study examined the effect of suction‐assisted laryngoscopy airway decontamination (SALAD) compared to intermittent suction in maintaining CPR quality during intubation in a simulated scenario of regurgitation. Methods: This randomized controlled manikin simulation study employed a manikin to simulate the regurgitation of gastric contents into the oropharynx during CPR. A total of 36 emergency medical technician‐paramedics participated in this study. Following a 2.5 h training on the SALAD technique, all participants were randomly assigned to use either the SALAD technique ( n = 18) or intermittent suction ( n = 18) during intubation on the manikin. The primary outcomes were CPR quality metrics, including chest compression rate, depth, and interruption time. The secondary outcomes were intubation success rate, intubation time, and glottic visualization during intubation. Results: The SALAD group demonstrated significantly higher chest compression rates compared to the intermittent suction group, both before (115.7 vs. 110.9 bpm, p < 0.01) and during intubation (112.9 vs. 108.4 bpm, p < 0.05). The proportion of compression depths ≥ 5 cm was higher in the SALAD group than in the intermittent suction group, both at preintubation (61.6% vs. 44.4%) and intubation periods (55.6% vs. 27.8%). However, these differences were not statistically significant. No significant difference was observed between the two groups regarding compression depths and interruption times. A significant decrease of 2.8 bpm was observed in the compression rate of the SALAD group during intubation compared to the preintubation period ( p < 0.01). In the intermittent suction group, both compression rates and depths exhibited a significant reduction during intubation (both p < 0.01) compared to the preintubation period. Intubation first‐pass success rate and intubation time were comparable between the two groups. While the best glottic visualization prior to intubation was comparable between the groups, during intubation, the SALAD group demonstrated a significantly higher proportion of complete glottic visibility compared to the intermittent suction group (72.2% vs. 22.2%, p < 0.01). Conclusions: The SALAD technique achieved higher chest compression rates and provided better glottic visualization compared to intermittent suction during intubation in contaminated airways.

Background: Regurgitation is a complication common during cardiopulmonary resuscitation (CPR). This manikin study evaluated the effect of regurgitation during endotracheal intubation on CPR quality. Methods: An airway-CPR manikin was modified to regurgitate simulated gastric contents into the oropharynx during chest compression during CPR. In total, 54 emergency medical technician-paramedics were assigned to either an oropharyngeal regurgitation or clean airway scenario and then switched to the other scenario after finishing the first. The primary outcomes were CPR quality metrics, including chest compression fraction (CCF), chest compression depth, chest compression rate, and longest interruption time. The secondary outcomes were intubation success rate and intubation time. Results: During the first CPR–intubation sequence, the oropharyngeal regurgitation scenario was associated with a significantly lower CCF (79.6% vs. 85.1%, P < 0.001), compression depth (5.2 vs. 5.4 cm, P < 0.001), and first-pass success rate (35.2% vs. 79.6%, P < 0.001) and greater longest interruption duration (4.0 vs. 3.0 s, P < 0.001) than the clean airway scenario. During the second and third sequences, no significant difference was observed in the CPR quality metrics between the two scenarios. In the oropharyngeal regurgitation scenario, successful intubation was independently and significantly associated with compression depth (hazard ratio = 0.47, 95% confidence interval, 0.24–0.91), whereas none of the CPR quality metrics were related to successful intubation in the clean airway scenario. Conclusion: Regurgitation during endotracheal intubation significantly reduces CPR quality. Trial registration: ClinicalTrials.gov, NCT05278923, March 14, 2022.

Two cirrhotic patients with unexplained abdominal pain deteriorated rapidly and fatally after presenting to our emergency department. Abdominal computed tomography in both patients showed “misty mesentery”, which could not be explained by other etiologies. Both blood cultures revealed Vibrio vulnificus, which suggested the possible correlation of CT-finding and bacteremia.