Articles: intubation.
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Difficult intubation has been classified into four grades, according to the view obtainable at laryngoscopy. Frequency analysis suggests that, in obstetrics, the main cause of trouble is grade 3, in which the epiglottis can be seen, but not the cords. This group is fairly rare so that a proportion of anaesthetists will not meet the problem in their first few years and may thus be unprepared for it in obstetrics. ⋯ Laryngoscopy is carried out as usual, then the blade is lowered so that the epiglottis descends and hides the cords. Intubation has to be done blind, using the Macintosh method. This can be helpful as part of the training before starting in the maternity department, supplementing the Aberdeen drill.
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In nine patients, with preoperative ICP monitoring, anaesthesia was induced with thiopentone 5 mg kg-1 given over 1 min, followed by pancuronium 0.1 mg kg-1. After manual hyperventilation with nitrous oxide and oxygen for 3 min they were given thiopentone 2.5 mg kg-1 over 30 s (phase 1); 30 s later laryngoscopy was performed and topical analgesia administered to the larynx. Endotracheal intubation was performed 1 min after spraying the cords (phase 2). ⋯ Although there was a significant decrease (P less than 0.05) in MAP at the end of the second dose of thiopentone, there were no other significant changes in ICP, MAP or PaCO2 throughout the study. In two patients there were transient decreases in cerebral perfusion pressure to less than 60 mm Hg. Although MAP increased in five of the patients during laryngoscopy and intubation, there was no increase in ICP, showing that the MAP was still within the autoregulatory limits.
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A pool of 146 mobile intensive care unit paramedics was divided into four equal groups and trained in the technique of direct laryngoscopic endotracheal intubation of cardiac arrest or deeply comatose patients. Group 1 was selected from supervisors and crew chiefs and trained as preceptors. The remaining paramedics were assigned to three other study groups. ⋯ A significant improvement in the skill was seen as the study progressed when groups are pooled and compared. The findings suggest that endotracheal intubation of deeply comatose or cardiac arrest patients is a field procedure that can be performed safely and skillfully by well-monitored paramedical personnel. Operating room or animal laboratory experience may increase initial success levels, but these factors do not appear to greatly influence eventual performance or incidence of complications of the procedure.