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Report by Simon Carley, Specialist Registrar Checked by John Butler, Specialist Registrar
Clinical scenario
A 55 year old woman is brought to the emergency department after an overdose of alcohol and tricyclic antidepressants. She has a tachycardia (110) and a systolic blood pressure of 105 mm Hg. The GCS is 5 (extends to pain). You decide to do an RSI using etomidate and suxamethonium. You are only able to visualise the epiglottis at laryngoscopy (Cormack grade 3 view), and struggle to intubate the patient on the third attempt (having intubated the oesophagus twice). You wonder if it would have been easier if you had used a gum elastic bougie.
Three part question
In [patients in with a poor laryngoscopic view] is [use of a gum elastic bougie better than simply using the ET tube] at [successfully and quickly achieving tracheal intubation]?
Search strategy
Medline 1966–07/2001 using the OVID interface. [{exp laryngoscopy OR laryngoscopy.mp OR exp intubation, intratracheal OR intubation.mp OR intubate$.mp} AND {bougie$ OR gum elastic.mp}] LIMIT to human AND english.
Search outcome
Altogether 78 papers were found of which one directly answered the three part question. This paper is shown in table 1.
Comments
Although the mean time for intubation is longer with the bougie the difference is clinically unimportant. Of greater interest is the number of patients who could not be intubated directly, but who were subsequently intubated using the bougie. Similarly, there were no prolonged intubation times in the bougie group. Use of a gum elastic bougie appears to ease intubation in a neutral c-spine position.
Clinical bottom line
A gum elastic bougie should be available as an aid to intubation during difficult laryngoscopy.
Report by Simon Carley, Specialist Registrar Checked by John Butler, Specialist Registrar