A fracture of the mandible is a common trauma presentation amongst young males and represents one of the most frequently encountered fractured bones within the viscerocranium. Historically, assault was the dominant contributing factor but now due to the increased number of vehicles used per capita, motor vehicle accidents are the primary cause. Mandibular fractures can be classified anatomically, by dentition, by muscle group and by severity. The fracture may also be closed, open, comminuted, displaced or pathological. It is important that the imaging modality used identifies the classification as this will decide definitive treatment. X-ray projections have typically been used to detect a mandibular fracture, but are limited to an anteroposterior (AP), lateral and oblique view in an unstable trauma patient. These views are inadequate to detail the level of fracture displacement and show poor detail of the condylar region. Computer tomography (CT) is the imaging modality of choice when assessing a traumatic mandibular injury and can demonstrate a 100% sensitivity in detecting a fracture. This is through use of a multidetector-row CT, which reduces motion blur and therefore produces accurate coronal and sagittal reconstructions. Furthermore, reconstructive three-dimensional CT images gained from planar views, allows a better understanding of the spatial relationship of the fracture with other anatomical landmarks. This ensures a better appreciation of the severity and classification of a mandibular fracture, which therefore influences operative planning. Ultrasound is another useful modality in detecting a mandibular fracture when the patient is too unstable to be transferred to a CT scanner. The sensitivity however is less in comparison to a CT series of images and provides limited detail on the fracture pattern. Magnetic resonance imaging demonstrates use in assessing soft tissue injury of the temporomandibular joint but this is unlikely to be of priority when initially assessing a trauma patient.

Study Objective: Structured review of video laryngoscopy recordings from physician team prehospital rapid sequence intubations (RSIs) may provide new insights into why prehospital intubations are difficult. The aim was to use laryngoscope video recordings to give information on timings, observed features of the airway, laryngoscopy technique, and laryngoscope performance. This was to both describe prehospital airways and to investigate which factors were associated with increased time taken to intubate. Methods: Sydney Helicopter Emergency Medical Service (HEMS; the aeromedical wing of New South Wales Ambulance, Australia) has a database recording all intubations. The database comprises free-text case detail, airway dataset, scanned case sheet, and uploaded laryngoscope video. The teams of critical care paramedic and doctor use protocol-led intubations with a C-MAC Macintosh size four laryngoscope and intubation adjunct. First-pass intubation rate is approximately 97%. Available video recordings and their database entries were retrospectively analyzed for pre-specified qualitative and quantitative factors. Results: Prehospital RSI video recordings were available for 385 cases from January 2018 through July 2020. Timings revealed a median of 58 seconds of apnea from laryngoscope entering mouth to ventilations. Median time to intubate (laryngoscope passing lips until tracheal tube inserted) was 35 seconds, interquartile range 28-46 seconds. Suction was required prior to intubation in 29% of prehospital RSIs. Fogging of the camera lens at time of laryngoscopy occurred in 28%. Logistic regression revealed longer time to intubate was associated with airway soiling, Cormack-Lehane Grade 2 or 3, multiple bougie passes, or change of bougie. Conclusion: Video recordings averaging 35 seconds for first-pass success prehospital RSI with an adjunct give bed-side “definitions of difficulty” of 30 seconds for no glottic view, 45 seconds for no bougie placement, and 60 seconds for no endotracheal tube placement. Awareness of apnea duration can help guide decision making for oxygenation. All emergency intubators need to be cognizant of the need for suctioning. Improving the management of bloodied airways and bougie usage may reduce laryngoscopy duration and be a focus for training. Video screen fogging and missed recordings from some patients may be something manufacturers can address in the future.

BACKGROUND: During videolaryngoscopy (VL), the larynx appears within the defined area of the video screen, and its location can be measured as a point within this space. Spatial statistics offer methods to explore the relationship between location data and associated variables of interest. The aims of this study were to use spatial point pattern analysis to explore if the position of the larynx on VL is associated with longer times to intubate, increased risk of a needing >1 intubation attempt, or percentage of glottic opening. METHODS: Quality assurance data and clinical notes from all prehospital intubations using C-MAC Pocket Monitor with CMAC-4 blade (Karl Storz) from January 1, 2018, to July 31, 2020, were reviewed. We extracted 6 measurements corresponding to the time taken to obtain the initial and then best laryngeal view, time to manipulate a bougie, and time to place the endotracheal tube, as well a percentage of glottic opening and a number of intubation attempts. Larynx location was the middle of the base of glottis, in cm from the left and bottom on the C-MAC screen. Two plots were produced to summarize the base of glottis location and time to perform each time component of intubation. Next, a cross mark function and a maximum absolute deviation hypothesis test were performed to assess the null hypotheses that the spatial distributions were random. The association between glottis location and >1 intubation attempt was assessed by a spatial relative risk plot. RESULTS: Of 619 eligible intubations, 385 had a video for analysis. The following time variables had a nonrandom spatial distribution with a tendency for longer times when the larynx was offcenter to the top or right of the screen: laryngoscope passing from teeth to glottis, glottis first view to best view of the larynx, time from bougie appearing to being placed in the cords, and overall time from teeth to endotracheal tube passing through cords. There was no increased relative risk for >1 intubation attempt. CONCLUSIONS: Spatial point pattern analysis identified a relationship between the position of the larynx during VL and prolonged intubation times. We did not find a relationship between larynx location and >1 attempt. Whether the location of the larynx on the screen is a marker for difficult VL or if optimizing the larynx position to the center of the screen improves intubation times would require further prospective studies. (Anesth Analg 2022;134:1288-96) KEY POINTS• Question: Is the position of the larynx on videolaryngoscopy associated with longer times to intubate or an increased risk of a second attempt at intubation, using spatial point pattern analysis? • Findings: Laryngeal location to the top and right of the screen is associated with longer times for intubation and bougie manipulation but not requirement for >1 attempt. • Meaning: Larynx location may be associated with intubation performance measures. GLOSSARY CCP = critical care paramedic; C-MAC = Karl Storz C-MAC videolaryngoscopy range; CMAC-4 = Karl Storz C-MAC macintosh siz...

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