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We read with interest the recent paper by Mackay and colleagues regarding the safety of prehospital rapid sequence induction by emergency physicians1 and would like to make two observations. Despite grading more of the patients as Cormack-Lehane 1 and 2 (95% compared with 81.5% in the emergency physician group) the anaesthetists were still using the gum elastic bougie more often (60.4% versus 51.0%). The use of the Cormack-Lehane scoring system is not necessarily predictive of intubation difficulty. Prehospital evaluation of intubation in France has showed that glottic exposure alone is an incomplete reflection of the difficulty encountered. In fact using a seven point scoring system, the influence of glottic visualisation was only moderate when assessing the subsequent degree of difficulty of intubation.2 Given that this is the case then should the use of an aid to intubation, such as the gum elastic bougie be part of the standard operating procedure for prehospital intubation? This may further reduce the number of repeat attempts at intubation, which the authors themselves comment as probably being under-reported in the study.
The authors also state that the laryngeal mask airway is not routinely carried. This is surprising given that, as an airway adjunct, while not providing protection from gastric aspiration, it may be available to provide oxygenation in circumstances where the provision of a definitive airway may be difficult. Its potential role in the prehospital setting should not be overlooked.3
We thank the authors of this letter for their comments. While we accept that simply grading the view at laryngoscopy is not the only factor predicting difficulty of intubation, it is convenient and well understood and may reflect potential problems.1 We agree that a gum elastic bougie should be used as a routine to aid prehospital intubation.
A laryngeal mask airway may certainly have a role as a backup device, but is not always easy to insert, particularly in the multiply injured patient requiring cervical stabilisation.2 Comparative studies are required to determine the best approach to a failed prehospital intubation.
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