EBQ:Effect of video laryngoscopy on trauma patient survival

Under Review Journal Club Article

Yeatts et al. "Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial". The Journal of Trauma and Acute Care Surgery. 2013. 75(2):212-219.
PubMed PDF

Clinical Question

Does the use of GlideScope video laryngoscopy affect survival to hospital discharge in adult patients requiring emergency airway management?

Conclusion

No mortality benefit was found with the use of GlideScope vs Direct Laryngoscopy(DL) in trauma patient intubation.

Use of the GlideScope in patients with severe head injury had a greater incidence of hypoxia and mortality on subgroup analysis.

Study Design

• Prospective randomized controlled trial
• Single Center: University of Maryland Shock Trauma Center

Population

• Adult patients in trauma resuscitation unit at requiring emergency intubation.
• N=623

Patient Demographics

• Age: 42.5
• Male: 73%
• Mechanism of Injury:
  • Blunt: 71.6%
  • Penetrating: 12%
  • Other: 6.1
• Injury Severity Score: 19 (Direct Laryngoscopy); 17 (GlideScope)

Inclusion Criteria

All adult patients requiring intubation according to the Eastern Association for the Surgery of Trauma guidelines:

1. Airway obstruction
2. Hypoventilation
3. Severe Hypoxemia
4. GCS≤8
5. Hemorrhagic Shock
6. Combativeness
7. Extreme pain

Exclusion Criteria

1. Minors
2. Patients with suspected laryngeal trauma or extensive maxillofacial injury
3. Need for immediate surgical airway
4. Spinal cord injury requiring fiber-optic intubation
5. Cardiac arrest on arrival
6. Death on arrival

Interventions

All patients received RSI with either thiopental or etomidate and succinlcholine followed by preoxygenation and inline cervical spine immobilization. Intubation was performed by an attending anesthesiologist or a EM or anesthesia resident with 1 year intubating experience. All intubations were recorded on video with digital capture of vital signs every 6 seconds. Time to intubation was defined as difference between mouth insertion and removal with confirmation via continuous capnography and physical exam. Multiple attempts were added together for cumulative time.

Outcome

Primary Outcomes

• Mortality rate: 7.5% (DL) vs 9.2% (GlideScope)

p = 0.43

Secondary Outcomes

Among all patients, median intubation attempt duration in seconds was significantly higher for the GVL group than for the DL group. No meaningful differences between the two groups were found in the first-pass success rates (81% for DL and 80% for GVL, p = 0.46).

Subgroup analysis

When intubation times between junior residents and senior residents and attending were compared, a statistically longer intubation times across skill levels associated with use of the GlideScope was identified (data not shown). Among those with severe head injuries, median intubation attempt duration in seconds was also significantly higher for the GVL group than for the DL group. Correspondingly, this group also experienced a greater incidence of low oxygen saturations of 80% or less (27 [50%] of 54 for the GVL group and 15 [24%] of 63 for the DL group, p = 0.004).

• First-pass Success: 81% (DL) vs. 80%(GlideScope)
• Intubation Duration: 56.5%(DL) vs. 71%(GlideScope)

Criticisms

Patients could be excluded according to attending discretion leading to noncompliance of protocol

Review Questions

1 Was there a difference to mortality between those intubated with GlideScope vs DL?

	Yes
	No

2 Did the use of GlideScope increase the duration of intubation attempt?

	Yes
	No

3 In what subgroup did the authors find a higher mortality in post hoc analysis?

	Those intubated by anesthesiology residents
	Severe head injury patients
	Those with blunt chest trauma
	Those with penetrating chest trauma