American Journal of Emergency Medicine 34 (2016) 1156-1180

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glottic view“>Correspondence

Sniff for a good glottic view?,??,?,??

Sir,

We read with great interest a meta-analysis published in your jour- nal by Akihisa et al titled “Effects of sniffing position for tracheal intuba- tion: a meta-analysis of randomized controlled trials” [1]. We congratulate the authors for working on the important and basic issue pertaining to laryngoscopy and intubation. Positioning during laryngos- copy is of immense importance for prehospital and resuscitation pro- viders in emergency settings also where, most of the time, professionals are not anesthesiologists.

Inference drawn by the meta-analysis that sniffing position does not offer added advantage over simple Head extension position for glottis exposure [1] may have significant impact on hospital and prehospital care. We went through the method adopted by all the studies analyzed in the meta-analysis, and although all these studies had a robust cross- over study design, their scale of assessment of glottis exposure is com- mon in all, and it is the ordinal Cormack Lehane Scale [2-4]. This we believe might not be a good scale to assess superiority of one view over the other. One can have a significantly better glottis exposure with the same Cormack Lehane grading. The change of glottis exposure quality needs to be significant for there to be a change in the Cormack Lehane grade, say from grade 3 to grade 2. Changes in glottic exposure due to positioning are likely to be subtle, and most of the Cormack Lehane grades shall be same in either position. Using this scale, one po- sition may not be proven to be better than the other despite it giving consistently better exposures when compared with the other.

We believe that this is an important aspect which the authors in par- ticular and experts in general may like to consider when interpreting re- sults from studies that have been analyzed in the meta-analysis. Sniffing position has been time tested and is still the most widely used initial po- sition for laryngoscopy and intubation.

Nishant Sahay, DNB Department of Anesthesiology, AIIMS Patna, Phulwarisharif, Patna, India Corresponding author. Department of Anesthesiology, AIIMS Patna House No. 112, Type 4 Block 1, AIIMS Residential Complex, Khagaul Patna, India. Tel.: +91 6122452035; fax: +91 6122452035

E-mail address: [email protected]

Abhishek Chatterjee, DNB

Department of Anesthesiology & Critical Care

TMH, Jamshedpur, India E-mail address: [email protected]

? Funding: None.

?? Previous presentation: None.

? Conflicts of interest: All authors reported no conflicts of interest.

?? Attestations: All authors approved the final manuscript.

Anubha Sahay, DMRD Dr. Anubha’s Imaging Centre, WALMI, Patna, India E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2016.02.041

References

1. Akihisa Y, Hoshijima H, Maruyama K, Koyama Y, Andoh T. Effects of sniffing position for tra- cheal intubation: a meta-analysis of randomized controlled trials. Am J Emerg Med 2015 Nov;33(11):1606-11. http://dx.doi.org/10.1016/j.ajem.2015.06.049 [Epub 2015 Jun 23].
2. Bhattarai B, Shrestha SK, Kandel S. Comparison of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy. Kathmandu Univ Med J (KUMJ) 2011;9:58-63.
3. Adnet F, Baillard C, Borron SW, Denantes C, Lefebvre L, Galinski M, et al. Randomized study comparing the “sniffing position” with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology 2001;95:836-41.
4. Prakash S, Rapsang AG, Mahajan S, Bhattacharjee S, Singh R, Gogia AR. Comparative evaluation of the sniffing position with simple head extension for laryngoscopic view and intubation difficulty in adults undergoing elective surgery. Anesthesiol Res Pract 2011;2011.

   The need for abdominal only CPR in the

   

   treatment of hemorrhagic shock and trauma arrests?,??

   To the Editor,

   Jeffcoach et al. [1] studied the utility of cardiopulmonary resuscita- tion (CPR) in a dog model of hemorrhagic shock. They found that chest compressions in addition to fluid administration did not reverse signs of shock better than fluid alone. They recommended that further research is needed to define if there is a role of CPR in the trauma patient with hemorrhagic shock. However, although they found that there was no benefit to performing chest compressions in hypovolemic animals, there may be a benefit to performing abdominal only CPR in conjunc- tion with fluid administration.

   Georgiou et al. [2] recently argued that although abdominal only CPR [3-7] may potentially increase the Coronary and cerebral perfusion pressure, there is very little evidence to support its application in the treat- ment of cardiac arrest. However, while there is little evidence to support the use of abdominal only CPR in the treatment of non-Traumatic cardiac arrest, there is evidence to support its use along with fluid administration in the treatment of hemorrhagic shock and traumatic arrests.

   After successful CPR, a frequent clinical observation is that the pa- tient remains hypotensive, has cardiogenic shock, and frequently dete- riorates rapidly; as a result, “abdominal only CPR (AO-CPR)” was

   ? Reprints: none.

   ?? Financial disclosures: none.

   0735-6757/(C) 2016