EBQ:Effect of video laryngoscopy on trauma patient survival

Complete 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 of blade 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

• First-pass Success: 81% (DL) vs. 80%(GlideScope)

p=0.46

Subgroup analysis

• Intubation Duration(seconds): 40 (DL) vs. 56 (GlideScope)
• Mortality in Head Injury: 16% (DL) vs 22% (GlideScope)

Criticisms

Although patients were randomized, the attending physician could choose to remove a patient from the study due to preference for DL or GlideScope. 210 of 898 eligible patients were excluded for this reason. Also, this study only uses the GlideScope video laryngoscope with the hyper-angulated blade, so abstraction to all videolaryngoscopy is not possible.