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BACKGROUND: An emergent front of neck airway (FONA) is needed when a \'can\'t intubate, can\'t oxygenate\' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS).
METHODS: This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed.
RESULTS: A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1).
CONCLUSIONS: The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.

Anaesthesia induced with remimazolam and a fentanyl-series opioid can be reversed with flumazenil and naloxone. Concomitant paralysis with rocuronium can facilitate tracheal intubation whilst being reversible with sugammadex. Together, this combination might offer full reversibility of a \'routine\' or a \'rapid-sequence\' induction anaesthesia. Whether this is useful, or even safe, requires careful evaluation.

OBJECTIVE: Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit.
METHODS: This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist.
RESULTS: Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation.
CONCLUSIONS: The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

OBJECTIVE: Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement.
METHODS: All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored.
RESULTS: A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt.
CONCLUSIONS: In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.

BACKGROUND: Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS).
METHODS: We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015-2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1- and 30-day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression.
RESULTS: A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1-day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37-0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68-1.04), but no difference in 30-day mortality (OR after implementation 1.10, 95% CI 0.92-1.30). Implementation of an SOP improved first-pass success rate from 87.3% to 96.5%, p < 0.001.
CONCLUSIONS: Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1-day mortality and an improved first-pass success but did not affect 30-day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly.

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In this case report, we describe two difficult intubations in which an endotracheal tube was threaded over a fiberoptic bronchoscope that was acting as a bougie. Our patients initially presented with limited neck extension, narrow mouth opening, and restricted view of the glottic region. A fiberoptic bronchoscope was guided through while the patient was oxygenated through a laryngeal mask. After the scope provided an unrestricted view of the vocal cords, the digital module was removed by cutting the fiberoptic thread, and an endotracheal tube was passed through. After proper confirmation of the endotracheal tube position, the intubation was deemed successful and thereby, we share our experience with the novel technique. This technique may potentially improve critical patient outcomes whether in trauma or an unexpectedly difficult intubation.

OBJECTIVE: In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile.
METHODS: Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded.
RESULTS: A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002).
CONCLUSIONS: It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better.
BACKGROUND: NCT05343702.

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