Resuscitation 53 (2002) 227 /228 www.elsevier.com/locate/resuscitation
Letters to the Editor
The ILMA in pre-hospital care Dr Mason is to be congratulated on presenting a difficult case with such openness and clarity [1]. I know only too well the problems of managing the compromised airway in the trapped patient [2]. I therefore remain cautious about the enthusiasm with which the ILMA is being advocated as a pre-hospital emergency airway device. My first concern is that no mention is made of surgical cricothyroidotomy in this case [3]. This is a safe technique which is easily taught, requires minimal equipment and provides a definitive airway when performed with a cuffed tracheostomy tube [4]. Although I accept that some patients may have difficult necks and that an LMA as a temporising measure may be appropriate in the trapped patient, the excellent photographs provided by Dr Mason illustrate that good access to the neck was possible. If an LMA were to be used as a temporising measure then perhaps one with an oesophageal vent would be better than an ILMA at minimising the hazards of regurgitation [5]. Secondly, in contrast to the conventional LMA, none of the eight A&E Departments in Cambridgeshire, Norfolk and Suffolk provide ILMA equipment in the resuscitation room (personal communication). Similarly, none of the hospital resuscitation training or anaesthetic departments provides training for ILMA use in the resuscitation room setting (personal communication). Dr Mason was required to intubate the patient in the resuscitation room of a major A&E department because the department had neither the equipment nor expertise to do so without first removing the ILMA. Thirdly, although there is evidence that the ILMA two-stage intubation technique can be taught to novices and naive intubators, almost 8% of elective ASA grade 1 and 2 patients could not be intubated through the ILMA within two attempts by experienced consultant anaesthetists [6]. Thus the assertion that the ILMA can be used as part of a two-stage technique in the prehospital environment by naive intubators requires further careful scrutiny before being widely advocated. Finally, the patient had isolated head and facial injuries and was trapped in the wreckage of a car for over 40 min before developing respiratory compromise. Survival following road traffic related injury appears
most likely to be determined by severity of initial injury and time to meaningful intervention (including early airway care). Had the mechanisms been in place to facilitate rapid extrication then, in my experience, the management of this patient would have been considerably easier. The real challenges for pre-hospital care are in developing such mechanisms.
References [1] Mason AM. Use of the intubating laryngeal mask airway in prehospital care: a case report Resuscitation, vol. 51, 2001:91 /5. [2] Mackenzie R, Sutcliffe R. The trapped patient J. R. Army Med. Corps, vol. 146, 2000:39 /46. [3] European Resuscitation Council. Guidelines for the advanced management of the airway and ventilation during resuscitation. Resuscitation 1996;31:201 /230. [4] Walls RM, Luten RC, Murphy MF, Schneider RE, editors. Manual of emergency airway management. Philadelphia: Lippincott, Wiliams and Wilkins, 2000. [5] Brain AIJ, Verghese C, Strube PJ. The LMA ProSeal-A Laryngeal Mask with an Oesophageal Vent B. J. Anaes., vol. 84, 2000:650 /4. [6] Baskett PJF, Parr MJ, Nolan JP. The intubating laryngeal mask Results of a multicentre trial with experience of 500 cases Anaesthesia, vol. 53, 1998:1174 /9.
Roderick Mackenzie 4 The Maltings, Godmanchester, Huntingdon, PE29 2JR, UK E-mail:
[email protected] PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 0 1 7 - 5
Emergency needle thoracocentesis
cricothyroid
puncture
and
Our attention has been drawn to potential problems in the techniques of emergency cricothyroid puncture and thoracocentesis as described in the advanced life support courses APLS, ATLS and ALS [1 /3]. These techniques usually recommend the attachment of a syringe to the end of an intravenous cannula to aid manipulation and to ensure that air can be aspirated when the trachea or pleural cavity is entered. With increased concern over the potential for needlestick injury, many departments have changed from using
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