Contrast-induced encephalopathy and diagnostic modalities - Can it make a difference?

Dear Editor,

Subramanian Senthilkumaran

Department of Emergency and Critical Care, Be Well hospitals, Erode, Tamil

Nadu, India Corresponding author at: Department of Emergency & Critical Care Medicine, Bewell Hospitals, Erode, Tamil Nadu, India.

E-mail address: [email protected]

We read the case report by Pokersnik et al. [1] with great interest. With reference to the report, the rarity of this complication makes it a diagnostic challenge that entails the exclusion of hemorrhagic causes. From the point of patient safety and quality of care, we would like to underscore the utility of Hounsfield units (HU) and other reliable image modalities that can differentiate contrast in- duced encephalopathy from other mimickers based on our experi- ence [2] and the literature.

The current standard of care for such discrimination is to repeat the imaging after 24 h as the contrast staining normally washes out within 24-48 h, while hemorrhage persists for days to weeks. This traditional approach will cause unnecessary delay. This differentiation is crucial in the setting of acute stroke or trauma, when antithrombotic therapy is being considered [3].

The measurement of the density of different visible elements in the CT scan with HU can assist in differentiating blood from contrast as con- trast media present higher attenuation (100-300 HU) than blood (40 to 60 HU). Additionally, this can be done with the available CT scans with- out any extra cost and done immediately even before the patient leaves the CT suite [4].

If Dual-energy CT is available, then it should be able to differentiate contrast staining in contrast-induced neurotoxicity form hemorrhage, this discrimination is based on the differences between the photoelec- tric and Compton scattering components underlying the X-ray attenua- tion of hemorrhage and iodine. Because both phenomena are dependent on the X-ray photon energy, one can discriminate the pixel attenuation arising from these 2 effects by scanning at 2 different energy levels, such as 80 kV and 140 kV. Assuming that there can only be hem- orrhage and/or iodine (in addition to water and tissue), this information can be used to determine the amount of each material present in each voxel [5].

However, MRI is also helpful in excluding cerebral ischemia and hemorrhage with contrast extravasation as there is no change in appar- ent diffusion coefficient values [6]. The CSF Examination is also useful, subarachnoid hemorrhage can be ruled out due to absence of xantochromia or red blood cells. Velden and his colleagues [7] per- formed simultaneous chemical analysis of Iomeprol concentration (io- dine contrast) in the CSF and serum. The Strong enrichment of Iomeprol in the CSF as conflicting to serum supported contrast extrava- sation rather than hemorrhage.

In view of the above, application and utilization of these technolo- gies shall be discussed while handling cases of CIE and the knowledge thus gained shall be imparted to students of health sciences and emer- gency physicians. Before making decisions or arriving diagnosis, let us always consider differential diagnosis and rule out each other using non-invasive and invasive technologies wherever feasible before arriv- ing diagnosis. This is important as many situations warrants supportive care, reassurance and masterly inactivity rather than active interven- tion, like cases of CIE.

Financial support

Nil.

Conflict of interest

Nil.

Namasivayam Balamurugan

Department of Neurosciences, SIMS Chellam Hospital, Salem, Tamil Nadu,

India

Narendra Nath Jena

Department of Emergency Medicine, Meenakshi Mission Hospital and

Research Centre, Madurai, Tamil Nadu, India

Ponniah Thirumalaikolundusubramanian Department of Internal Medicine, Chennai Medical College Hospital and Research Center, Irungalur, Trichy, Tamil Nadu, India

16 April 2018

https://doi.org/10.1016/j.ajem.2018.04.042

References

1. Pokersnik JA, Lou L, Simon EL. Contrast-induced encephalopathy presenting as acute subarachnoid hemorrhage. Am J Emerg Med 2018 Jun;36(6):1122.e3-1122.e4.
2. Senthilkumaran S, Karthikeyan N, Balamurugan N, Thirumalaikolundusubramanian P. Hounsfield units in pseudo subarachnoid hemorrhage: worth looking for. Clin Exp Emerg Med 2017 Sep 30;4(3):186-7.
3. Mericle RA, Lopes DK, Fronckowiak MD, et al. A grading scale to predict outcomes after intra-arterial thrombolysis for stroke complicated by contrast extravasation. Neurosurgery 2000;46:1307-14.
4. Senthilkumaran S, Sweni S, Balamurugan N, Jena NN, Thirumalaikolundusubramanian P. Hounsfield units in pseudo-subarachnoid hemorrhage-an old yet fascinating tool. Am J Emerg Med 2015;33:1095.
5. Phan CM, Yoo AJ, Hirsch JA, Nogueira RG, Gupta R. Differentiation of hemorrhage from iodinated contrast in different intracranial compartments using dual-energy Head CT. AJNR Am J Neuroradiol 33 (6): 1088-94.
6. Yu J, Dangas G. Commentary: new insights into the risk factors of contrast-induced encephalopathy. J Endovasc Ther 2011;18:545-6.
7. Velden J, Milz P, Winkler F, Seelos K, Hamann GF. Nonionic contrast neurotoxicity after coronary angiography mimicking subarachnoid hemorrhage. Eur Neurol 2003; 49:249-51.

   Concussion awareness among children and their care givers

   Recently, there has been considerable public interest in sport-related concussions and their outcomes, resulting in a substantial multidisci- plinary focus on concussion prevention and a push for greater public awareness [1-3]. The incidence of adolescent sport-related concussions is based on diagnosis as reported by physicians, athletic trainers, coaches, and other care providers. However, it is unclear if the symp- toms of concussion or the types of injuries that cause concussion are easily recognizable by children or their caregivers [4-9]. As a result, many potential concussions go unreported, and some athletes continue to play while symptomatic, leading to worsening injury and greater bur- den of disease [10-12]. Recent guidelines recommend that concussed athletes be removed from play and have a gradual Return to play once asymptomatic [13,14]. Both recognition of the symptoms characteristic of concussion and receipt of timely post-concussion care are important, and numerous legislative efforts have been made with some positive ef- fect in this regard [15-19].

   To assess the awareness of caregivers and children regarding con- cussion, a bilingual questionnaire (Table 1) was given to caregivers and children between the ages of 13 and 18 years who presented to the Emergency Department (ED) during a two year period.

   Table 1

   The questions are: (in Spanish and English).

   Nino (a) O Edad O Masculino O Femenino

   Usted esta invitado a participar de esta encuesta. Puede reuzarse a participar y esto no prolongara o afectara de ninguna forma su cuidado en la sala de Emergencias.

   1 Ha oido algo acerca de la concusion?	O Si	O No
   2 Sabe cuales son los sintomas de concusion?	O Si	O No
   3 Reconoceria los sintomas de concusion?	D Si	D No
   4 Sabe que hacer si observa esos sintomas?	0 Si	D No
   5 Sabe que puede causar una concusion?	O Si	D No

   6 Ha experimentado alguna vez sintomas de concusion luego de una lesion en deportes o

   accidente? Spanish version Padre o encargado

   O Si

   D No

   i. Ha oido algo acerca de la concusion?	O Si	D No
   2. Sabe cuales son los sintomas de concusion?	O Si	D No
   3. Reconoceria los sintomas de concusion?	D Si	D No
   4. Sabe que hacer si observa esos sintomas?	0 Si	ONo
   . Sabe que puede causar una concusion?	D Si	D No
   Nino (a) O Edad	O Masculino	O Femenino

   Usted esta invitado a participar de esta encuesta. Puede reuzarse a participar y esto no prolongara o afectara de ninguna forma su cuidado en la sala de Emergencias.

   1 Ha oido algo acerca de la concusion?	O Si	O No
   2 Sabe cuales son los sintomas de concusion?	O Si	D No
   3 Reconoceria los sintomas de concusion?	O Si	D No
   4 Sabe que hacer si observa esos sintomas?	D Si	D No
   5 Sabe que puede causar una concusion?	D Si	D No

   6 Ha experimentado alguna vez sintomas de concusion luego de una lesion en deportes o accidente? D Si D No

   Table 2

   The number of children and care giver with their corresponding responses.

   A. Number of children and care giver with percentage

   children	Heard about concussion	know symptoms of concussion	Recognize symptoms of concussion	Know what to do for concussion	Know causes of concussion	Past experience of concussion
   Total No	94 (28.5%)	226 (68.5%)	233 (70.6%)	248 (75.2%)	135 (41%)	296 (90%)
   Yes	236 (71.5%)	104 (31.5%)	97 (29.4%)	82 (24.8%)	195 (59%)	33 (10%)
   Care giver	Heard about concussion	Know symptoms of	Recognize symptoms of	Know what to do for	KNOW causes of
   		concussion	concussion	concussion	concussion
   No	203 (52%)	264 (67.5%)	261 (66.8%)	265 (67.8%)	211 (54%)
   Yes	188 (48%)	127 (32.5%)	130 (33.2%)	126 (32.2%)	180 (46%)
   B. Number of male and female with Percentage
   Child	Heard about concussion	Know symptoms of	Recognize symptoms of	Know what to do for	Know causes of	Past experience of
   		concussion	concussion	concussion	concussion	concussion
   Male No	50 (30.9%)	100 (61.7%)	104 (64.2%)	126 (77.8%)	71 (43.8%)	144 (88.9%)
   Yes	112 (69.1%)	62 (38.3%)	58 (35.8%)	36 (22.2%)	91 (56.2%)	18 (11.1%)
   Female No	44 (26.2%)	126 (75%)	129 (76.8%)	122 (72.6%)	64 (38.1%)	152 (91%)
   Yes	124 (73.8%)	42 (25%)	39 (23.2%)	46 (27.4%)	104 (61.9%)	15 (9%)

   From a total of 500 patients surveyed, 391 caregivers and 330 chil- dren were included in the final analysis, after removal of incomplete questionnaires [male 162 (49%) and female 168 (51%)]. While 71.5% of surveyed children had heard about concussion, 68.5% did not know the symptoms that would identify a concussion, and 75% would not know what to do if recognized. Forty one percent did not know the causes of concussion. A total of 10% of children reported experiencing concussion in the past. Of the surveyed caregivers, 48% had heard about concussion, but 67.5% did not know the symptoms that would identify concussion and 67.8% would not know what to do if recognized. Fifty four percent did not know the causes of concussion. (Table 2A and B).

   As our study demonstrated, awareness of the causes of concussion, the associated symptoms, and appropriate management once identified is fairly low. Of the surveyed children, about 10% reported a history of con- cussion. Unfortunately, the questionnaire did not ask participants whether or not they sought medical care or if they experienced resultant neurocognitive or psychiatric problems after the concussion.

   Concussion is a functional disturbance of the brain after injury [20- 23]. Contrary to popular belief and media emphasis on sport-related concussions, post-traumatic concussions may occur under a variety of conditions, including falls or other accidents. Additionally, while male athletes make up a greater proportion of contact-sports participants, it is important to note that female athletes can suffer similar injuries. In fact, a higher incidence of concussion was observed in young female Soccer players; several factors contributed to this finding, including heading and direct player-to-player contact. [24-26].

   Children with vulnerable brain tissue are at risk for adverse long-term outcomes from unrecognized and improperly managed concussion. The ability to recognize the initial symptoms may lead to improved identifica- tion of concussed children who can then benefit from proper post-concus- sion care. This will in turn help them prevent the negative sequelae of the disease [4,8,10,13,23,27-33]. Studies have demonstrated both neuro- cognitive and fine motor deficits as well as psychiatric problems after con- cussion in previously asymptomatic children [14,34,35]. Prevention of injury remains the best strategy for improving outcomes, and great effort should be made to educate and emphasize the use of protective equip- ment [36,37]. Ultimately, improved awareness will help at-risk children on a larger scale by leading to legislative recommendations and implementation of safety guidelines; this must also be supported by statis- tics of concussion-related injuries with the ultimate goal being a reduction in concussions [38-40]. Newer tests and diagnostic tools that may aid in concussion diagnosis are only currently available in research settings [23,41-46]. Familiarity with concussion and its symptoms is of paramount importance, particularly for family members, teachers and health care professionals [47]. Concussions are underreported for various reasons in all healthcare settings, including the ED, where the injured child often en- counters a medical professional for the first time [48]. As the point of entry is not always the ED, raising awareness by distributing pamphlets and

   participating in community-based educational programs may improve symptom-recognition, which in turn will allow for appropriate initial management and ability to seek proper post-concussion care.

   In summary, medical professionals have great potential to raise awareness and educate the public on concussion recognition by initiating social media campaigns and offering informational pamphlets in various healthcare settings, sport facilities and schools. This will ultimately lead to more appropriate concussion care, thereby improving outcomes for these children.

   This study is limited by small sample size and absence of questions addressing specific Concussion symptoms or the specific cause of re- ported concussion. Additionally, no follow-up questions were included on receipt of medical care or presence of neuropsychiatric problems after the reported concussion.

   Getaw Worku Hassen, MD, PhD?

   Nicholas Tinnesz Michelle Popkin, MD

   Jorge Alejandro Cardenas Villa, MD

   Hossein Kalantari, MD

   Department of Emergency Medicine, Metropolitan Hospital Center,

   United States

   ?Corresponding author.

   E-mail address: [email protected] (G.W. Hassen).

   Jovan Mirkovic

   St. John’s University, Queens, New York, United States

   Abhishek Pingle

   Case Western Reserve University, Cleveland, OH, United States

   Christine Umandap, MD Visalakshi Sethuraman, MD

   Department of Pediatrics, Metropolitan Hospital Center, United States

   Richard Warren

   Toro College Physician Assistant Program, United States

   13 March 2018

   https://doi.org/10.1016/j.ajem.2018.04.048

   References

   Kirkwood MW, Randolph C, Yeates KO. Sport-related concussion: a call for evidence and perspective amidst the alarms. Clin J Sport Med 2012;22:383-4. https://doi.org/ 10.1097/JSM.0b013e31826396fc.

8. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics 2006;117: 1359-71. https://doi.org/10.1542/peds.2005-0994.
9. Randolph C, Kirkwood MW. What are the real risks of sport-related concussion, and are they modifiable? J Int Neuropsychol Soc 2009;15:512-20. https://doi.org/10. 1017/S135561770909064X.
10. Halstead ME, Eagan Brown B, McAvoy K. Cognitive rest following concussions: re- thinking ‘cognitive rest’. Br J Sports Med 2017;51:147. https://doi.org/10.1136/ bjsports-2016-096674.
11. Halstead ME, Walter KD, Council on Sports, M. & Fitness, American Academy of Pediatrics. Clinical report-sport-related concussion in children and adolescents. Pediatrics 2010;126:597-615. https://doi.org/10.1542/peds.2010-2005.
12. Harmon KG, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med 2013;23:1-18. https://doi.org/10.1097/JSM. 0b013e31827f5f93.
13. Walter KD, Halstead ME. Concussion in teenage athletes. Adolesc Med State Art Rev 2015;26:39-52.
14. Echlin PS, et al. The Sport Concussion Education Project. A brief report on an educa- tional initiative: from concept to curriculum. J Neurosurg 2014;121:1331-6. https:// doi.org/10.3171/2014.8.JNS132804.
15. Echlin PS, et al. Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. Neurosurg Focus 2010;29(E5). https://doi.org/10.3171/ 2010.9.FOCUS10210.
16. https://www.npr.org/sections/health-shots/2018/01/18/578355877/repeated- head-hits-not-concussions-may-be-behind-a-type-of-chronic-brain-damage.
17. Omalu B. Chronic traumatic encephalopathy. Prog Neurol Surg 2014;28:38-49. https://doi.org/10.1159/000358761.
18. Iverson GL, Gaetz M, Lovell MR, Collins MW. Cumulative effects of concussion in amateur athletes. Brain Inj 2004;18:433-43. https://doi.org/10.1080/02699050310001617352.
19. Lovell MR, Fazio V. Concussion management in the child and adolescent athlete. Curr Sports Med Rep 2008;7:12-5. https://doi.org/10.1097/01.CSMR.0000308671.45558.e2.
20. Majerske CW, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train 2008;43:265-74. https://doi.org/10. 4085/1062-6050-43.3.265.
21. Gibson TB, Herring SA, Kutcher JS, Broglio SP. Analyzing the effect of state legislation on health care utilization for children with concussion. JAMA Pediatr 2015;169: 163-8. https://doi.org/10.1001/jamapediatrics.2014.2320.
22. Trojian T, Violano P, Hall M, Duncan C. The effects of a state concussion law on the frequency of sport-related concussions as seen in two emergency departments. Inj Epidemiol 2015;2:2. https://doi.org/10.1186/s40621-015-0034-7.
23. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus 2012;33(E11):11-9. https://doi.org/10.3171/2012.9.FOCUS12280.
24. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR. The effects of concussion leg- islation one year later-what have we learned: a descriptive pilot survey of youth soccer player associates. PM R 2012;4:427-35. https://doi.org/10.1016/j.pmrj.2012.02.016.
25. Baker DR, Kulick ER, Boehme AK, Noble JM. Effects of the New York State Concussion Management and Awareness Act (“Lystedt Law”) on concussion-related emergency health care utilization among adolescents, 2005-2015. Am J Sports Med 2018;46: 396-401. https://doi.org/10.1177/0363546517738742.
26. Echlin PS, Grady MS, Timmons SD. Concussion: pathophysiology and sequelae. Neurosurg Focus 2012;33 (Introduction: 1-2) https://doi.org/10.3171/2012.10. FOCUS12357.
27. Grubenhoff JA, et al. Acute concussion Symptom severity and delayed symptom res- olution. Pediatrics 2014;134:54-62. https://doi.org/10.1542/peds.2013-2988.
28. Grubenhoff JA, Kirkwood MW, Deakyne S, Wathen J. Detailed concussion symptom analysis in a paediatric ED population. Brain Inj 2011;25:943-9. https://doi.org/10. 3109/02699052.2011.597043.
29. Lovell MR, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery 2007;61:352-9 (discussion 359- 360) https://doi.org/10.1227/01.NEU.0000279985.94168.7F.
30. Strand S, Lechuga D, Zachariah T, Beaulieu K. Relative risk for concussions in young female soccer players. Appl Neuropsychol Child 2015;4:58-64. https://doi.org/10. 1080/21622965.2013.802650.
31. Comstock RD, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An evidence-based discussion of heading the ball and concussions in high school soccer. JAMA Pediatr 2015;169:830-7. https://doi.org/10.1001/jamapediatrics.2015.1062.
32. https://www.prnewswire.com/news-releases/female-soccer-players-suffer-the- most-concussions-in-high-school-sports-300422632.html.
33. DeMatteo C, et al. Post-concussion return to play and return to school guidelines for children and youth: a scoping methodology. Disabil Rehabil 2014:1-6. https://doi. org/10.3109/09638288.2014.952452.
34. DeMatteo C, et al. Development of a conservative protocol to return children and youth to activity following concussive injury. Clin Pediatr 2015;54:152-63. https:// doi.org/10.1177/0009922814558256.
35. DiFazio M, Silverberg ND, Kirkwood MW, Bernier R, Iverson GL. Prolonged activity restriction after concussion: are we worsening outcomes? Clin Pediatr 2016;55: 443-51. https://doi.org/10.1177/0009922815589914.
36. Echlin PS. Concussion education, identification,and treatment within a prospective study of physician-observed junior ice hockey concussions: social context of this sci- entific intervention. Neurosurg Focus 2010;29:E7. https://doi.org/10.3171/2010.10. FOCUS10222.
37. Kinnaman KA, Mannix RC, Comstock RD, Meehan 3rd WP. Management of pediatric patients with concussion by emergency medicine physicians. Pediatr Emerg Care 2014;30:458-61. https://doi.org/10.1097/PEC.0000000000000161.
38. Kirkwood MW, Randolph C, Yeates KO. Returning pediatric athletes to play after con- cussion: the evidence (or lack thereof) behind baseline neuropsychological testing. Acta Paediatr 2009;98:1409-11. https://doi.org/10.1111/j.1651-2227.2009.01448.x.
39. Connery AK, Peterson RL, Baker DA, Randolph C, Kirkwood MW. The role of neuro- psychological evaluation in the clinical Management of Concussion. Phys Med Rehabil Clin N Am 2016;27:475-86. https://doi.org/10.1016/j.pmr.2015.12.001.
40. Servatius RJ, et al. Neurocognitive and fine motor deficits in asymptomatic adoles- cents during the subacute period after concussion. J Neurotrauma 2018. https:// doi.org/10.1089/neu.2017.5314.
41. Ellis MJ, et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr 2015;16:709-18. https://doi.org/10.3171/2015.5.PEDS15220.
42. Daneshvar DH, et al. Helmets and mouth guards: the role of personal equipment in preventing sport-related concussions. Clin Sports Med 2011;30:145-63. https://doi. org/10.1016/j.csm.2010.09.006.
43. Patel DR, Fidrocki D, Parachuri V. Sport-related concussions in adolescent athletes: a critical Public health problem for which prevention remains an elusive goal. Transl Pediatr 2017;6:114-20. https://doi.org/10.21037/tp.2017.03.08.
44. https://www.washingtonpost.com/news/to-your-health/wp/2017/10/19/state- laws-have-reduced-concussion-risks-in-high-school-kids-study-finds/?utm_ term=.bfc075f5b8c9.
45. Mackenzie B, et al. Impact of a state concussion law on pediatric emergency depart- ment visits. Pediatr Emer Care 2015;31:25-30. https://doi.org/10.1097/PEC. 0000000000000325.
46. Zemek R. Pediatric concussion guidelines. Canadian family physician Medecin de famille canadien, 60; 2014; 890-2.
47. https://www.npr.org/sections/health-shots/2017/05/04/526782407/spit-test-may- reveal-the-severity-of-a-child-s-concussion?sc=17&f=1001&utm_source= iosnewsapp&utm_medium=Email&utm_campaign=app.
48. Difiori JP, Giza CC. New techniques in concussion imaging. Curr Sports Med Rep 2010;9:35-9. https://doi.org/10.1249/JSR.0b013e3181caba67.
49. Johnston KM, Ptito A, Chankowsky J, Chen JK. New frontiers in diagnostic imaging in concussive head injury. Clin J Sport Med 2001;11:166-75.
50. Pulsipher DT, Campbell RA, Thoma R, King JH. A critical review of neuroimaging ap- plications in sports concussion. Curr Sports Med Rep 2011;10:14-20. https://doi. org/10.1249/JSR.0b013e31820711b8.
51. Lovell MR, Collins MW. New developments in the evaluation of sports-related con- cussion. Curr Sports Med Rep 2002;1:287-92.
52. https://www.medscape.com/viewarticle/892683?nlid=120701_3901&src=wnl_ newsalrt_180214_MSCPEDIT&uac=156661CX&impID=1559441&faf=1.
53. Normandin PA, Benotti SA. Pediatric concussion update: what ED nurses should know after “humpty dumpty” falls. J Emerg Nurs 2018. https://doi.org/10.1016/j. jen.2017.12.010.
54. https://www.medpagetoday.com/meetingcoverage/acep/68955.

    The usage of Ambu(R) AuraGain(TM) laryngeal mask airway by the lifeguards

    Sir,

    We read with a great interest the article “Which option for ventilation is optimal for resuscitation performed by nurses? Pilot data” by Kaminska et al. [1], published in The Journal of the American Journal of Emergency Medicine. The article raises a vital issue of correct ventilation and main- taining the airway patency by the less experienced medical personnel. However, not only medical personnel such as doctors, paramedics or nurses encounter the situations when they have to provide a breathing support in patient with respiratory failure. Due to the nature of their work the lifeguards might need to provide help to a patient with sudden cardiac arrest caused by drowning. As it is crucial to minimize pauses dur- ing chest compressions when performing resuscitation, it seems reason- able to use the supraglottic airway devices and provide a patient with Continuous chest compressions, rather than performing resuscitation based on the standard sequence of 30 chest compressions followed by 2 rescue breaths, which are usually performed with a self-expanding bag with a face mask attached. Second-generation Supraglottic airway devices significantly improve the comfort of airway protection when compared to the first generation of those devices [2]. Due to the introduction of a chan- nel into the devices, which allows us to empty the stomach from excess air, it is possible to provide chest compressions of higher effectiveness. Numerous clinical studies and those conducted in simulated environment indicate that the supraglottic airway devices are easy to use just after a short training [3,4]. Furthermore, it is possible to perform “blind intuba- tion” with some of the devices with the usage the device’s air channel, which serves as guide for the endotracheal tube [5,6]. Obviously we must remember that after the device is implemented, we need to auscul- tate the patient to confirm the correct location of the device, which ex- cludes the pneumothorax which is potentially reversible cause of cardiac arrest. In addition, when dealing with patients in whom we