Chapter 2 Introduction

Vomiting and regurgitation are commonly encountered in out-hospital-cardiac arrest (OHCA) with a reported incidence of 20–30% (Benger et al. 2018; Voss et al. 2014; Simons et al. 2007). This is of concern since patients who have suffered an OHCA, are already in extremis and there is limited evidence that the presence of emesis leads to a reduction in odds of survival (Simons et al. 2007). If standard suctioning techniques are not sufficient to maintain a clear airway and provide ventilation, then these patients will die, irrespective of the quality of chest compressions and the timeliness of defibrillation. Arguably, tracheal intubation is the preferred airway management technique in patients with ongoing airway contamination, but there is evidence that this is difficult to achieve when the airway is soiled (Sakles et al. 2017). Early intubation may also help prevent aspiration pneumonias which are thought to adversely affect survival outcome, although this has yet to be proved empirically (Christ et al. 2016).

Traditional suctioning techniques have been criticised, and paramedic training in the management of contaminated airways, limited. This has led to the development of a combined suction/laryngoscopy technique to facilitate intubation, known as Suction Assisted Laryngoscopy and Airway Decontamination (SALAD), and the creation of modified airway manikins to allow for practice in these techniques (DuCanto, Serrano, and Thompson 2017).

However, to date there has only been one study specifically looking at the SALAD technique and the outcomes were limited to self-reported confidence measures of trainees using the technique. Other techniques have been described to manage significant airway contamination, including the use of a meconium aspirator (Kei and Mebust 2017), which requires a device that is not typically carried by UK ambulance services, and deliberate intubation of the oesophagus (the oesophageal diversion manoeuvre), of which the sum total of evidence in support of the procedure is a single case report (Kornhall et al. 2015).

This study aimed to determine whether a short teaching session of the SALAD technique to paramedics, improved their ability to successfully intubate a contaminated airway. The primary objective was to determine the difference between paramedic first-pass intubation success, before and after SALAD training, in a simulated soiled airway. The secondary objective was to determine the difference in time taken to achieve first-pass intubation success, before and after SALAD training in a simulated soiled airway, since it was hypothesised that the time to successful intubation might improve as a result of repeated attempts at intubation i.e. be due to a practice effect, rather than the SALAD technique alone.

References

Benger, Jonathan R., Kim Kirby, Sarah Black, Stephen J. Brett, Madeleine Clout, Michelle J. Lazaroo, Jerry P. Nolan, et al. 2018. “Effect of a Strategy of a Supraglottic Airway Device Vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial.” JAMA 320 (8): 779–91. https://doi.org/10.1001/jama.2018.11597.

Voss, Sarah, Megan Rhys, David Coates, Rosemary Greenwood, Jerry P. Nolan, Matthew Thomas, and Jonathan Benger. 2014. “How Do Paramedics Manage the Airway During Out of Hospital Cardiac Arrest?” Resuscitation 85 (12): 1662–6. https://doi.org/10.1016/j.resuscitation.2014.09.008.

Simons, Reed W., Thomas D. Rea, Linda J. Becker, and Mickey S. Eisenberg. 2007. “The Incidence and Significance of Emesis Associated with Out-of-Hospital Cardiac Arrest.” Resuscitation 74 (3): 427–31. https://doi.org/10.1016/j.resuscitation.2007.01.038.

Sakles, John C., G. Judson Corn, Patrick Hollinger, Brittany Arcaris, Asad E. Patanwala, and Jarrod M. Mosier. 2017. “The Impact of a Soiled Airway on Intubation Success in the Emergency Department When Using the GlideScope or the Direct Laryngoscope.” Edited by Rob Reardon. Academic Emergency Medicine 24 (5): 628–36. https://doi.org/10.1111/acem.13160.

Christ, Martin, Katharina Isabel von Auenmueller, Scharbanu Amirie, Benjamin Michel Sasko, Michael Brand, and Hans-Joachim Trappe. 2016. “Early-Onset Pneumonia in Non-Traumatic Out-of-Hospital Cardiac Arrest Patients with Special Focus on Prehospital Airway Management.” Medical Science Monitor : International Medical Journal of Experimental and Clinical Research 22 (June): 2013–20. https://doi.org/10.12659/MSM.896867.

DuCanto, James, Karen Serrano, and Ryan Thompson. 2017. “Novel Airway Training Tool That Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System.” Western Journal of Emergency Medicine 18 (1): 117–20. https://doi.org/10.5811/westjem.2016.9.30891.

Kei, Jonathan, and Donald P. Mebust. 2017. “Comparing the Effectiveness of a Novel Suction Set-up Using an Adult Endotracheal Tube Connected to a Meconium Aspirator Vs. A Traditional Yankauer Suction Instrument.” Journal of Emergency Medicine 52 (4): 433–37. https://doi.org/10.1016/j.jemermed.2016.09.006.

Kornhall, D. K., S. Almqvist, T. Dolven, and L. M. Ytrebø. 2015. “Intentional Oesophageal Intubation for Managing Regurgitation During Endotracheal Intubation.” Anaesthesia and Intensive Care 43 (3): 412–14.