This week, like Simon, I was invited to speak at SASEM: the Saudi Arabian Emergency Medicine society’s annual conference. I would have liked to visit in person. However, COVID-19 and work commitments meant that I presented virtually. The first talk I was asked to give was entitled ‘Airway Catastrophes’.
I certainly don’t purport to be an expert at ‘airway catastrophes’. In fact, during the pandemic it’s been much harder to maintain my own skills in airway management. Most of the patients with acute respiratory illness who require intubation will be taken to the ICU for intubation, or the anaesthetists will come down to the ED. Other than managing cardiac arrests with compromised airways [more on that later!], this means it’s been challenging to maintain competency during the pandemic.
That being so, I talked about the latest evidence for airway management. You can access a recording of my talk at the link below.
Here are the bottom lines:
Advanced airway management in out of hospital cardiac arrest
Like Simon, I highlighted the landmark AIRWAYS-2 trial. This was a cluster randomised controlled trial in which paramedics were randomised to treat their patients in out of hospital cardiac arrest either with an intubation first approach or a supraglottic airway first approach. Over 9,000 patients were included. There was no significant difference in the primary outcome (good outcome on the modified Rankin scale, defined as 0-3 points). What’s more, the supraglottic airway group more often had successful initial ventilation and there was no difference in complications.
I also highlighted a large systematic review published in Prehospital Emergency Care. This included over 90 studies with over 630,000 patients. The authors found that there was no evidence that prehospital endotracheal intubation led to patient benefit in the context of adult or paediatric cardiac arrest or in trauma. Controversial? You bet. But the evidence is what it is. Watch the video below to get my more detailed take on it.
Next, I discussed recent evidence on the use of video laryngoscopy, and some hot-off-the-press evidence-based tips for improving your first pass success rate. And finally we discuss a paper reporting on 20 years of experience with surgical airways in the London Ambulance Service. Patients undergoing prehospital surgical cricothyroidotomy had a massively high mortality rate. This is despite a 97% success rate for the procedure itself. It was therefore heartening to read that far fewer patients now undergo the procedure thanks to the introduction of supraglottic airways in the failed intubation protocol. In a failed intubation scenario, ensuring adequate ventilation is of course absolutely essential – and the use of supraglottic airways (like ProSeal or iGel) can allow rapid rescue ventilation.
At the conference, I also talked about ‘Practice Changing Papers of 2021’. In that, I covered the RECOVERY trial and the rationale for using dexamethasone only in hospitalised patients with COVID-19 who require oxygen. I also covered the RECOVERY trial’s positive evaluation of tocilizumab for patients with severe COVID pneumonia. There’s a little tour into diagnostics and our own moonshot programme evaluation of lateral flow tests for COVID-19. Lateral flow testing has become part of our lives. Work by our team really helped us to understand the sensitivity of those tests.
I also covered a great randomised controlled trial comparing helmet versus facemask CPAP. There’s coverage of the RAPID-CTCA trial evaluating coronary CT coronary angiography for patients with acute coronary syndromes. And there’s an intriguing trial comparing antibiotics to surgery for appendicitis. Antibiotics were non-inferior to surgery. I discuss what ‘non-inferior’ means as well as summarising the headlines of that trial. It’s all covered here…
Lastly, I talked about my ‘home’ topic – rapid rule-out of acute myocardial infarction and understanding troponins. I gave an update on T-MACS and a sneak preview of the findings of the PRESTO (Pre-hospital Evaluation of Sensitive Troponin) study. How sensitive is T-MACS when used with point of care troponin testing in the ambulance? You get get an early look at our preliminary analyses in the final video below!
As an aside, I used Prezi Videos to create my virtual presentations for the first time. It was a great experience! The interface allows you to present next to your slides with slick transitions between a full slide view, full speaker view and a split screen.
It was an honour to be invited to SASEM. I wish I could’ve been there in person, but even via Zoom it was great to see the packed conference rooms, the energetic speakers and moderators and the introduction of what looked like a terrific debate session. Hopefully it won’t be too long before face to face conferences are back as the norm, though it is fantastic to have the flexibility of hybrid arrangements as we did at SASEM 2022.