Precedir la vía aérea difícil en sala de urgencias
Precede the difficult airway in the emergency room
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Saavedra, M. Ángel, Almarales, J. R., & Becerra, E. (2015). Precedir la vía aérea difícil en sala de urgencias. Revista Repertorio De Medicina Y Cirugía, 24(3), 173–181. https://doi.org/10.31260/RepertMedCir.v24.n3.2015.612
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Esta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-CompartirIgual 4.0.
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Objetivo: revisar la literatura sobre vía aérea difícil en el servicio de urgencias, los predictores y las medidas de rescate cuando ocurre. Materiales y métodos: se revisaron en MEDLINE, EBSCOhost, SpringerLink y ScienceDirect con los términos difficult airway, vía aérea difícil, prolonged intubation, intubación prolongada, difficult intubation, intubación difícil, management of dificult airway, manejo de la vía aérea y predictores de vía aérea difícil, del año 2000 a 2014 en inglés o español. Resultados: se encontraron 16 estudios descriptivos prospectivos, 10 revisiones de tema, 7 registros de bases de datos, cuatro descriptivos transversales, cuatro comparativos, tres ciegos randomizados, dos guías de práctica clínica, dos series, un reporte de caso, dos análisis retrospectivos y un estudio de casos y controles. Conclusiones: la mayoría se han realizado en anestesiología, aunque en urgencias hay buenas tasas de éxito en vía aérea difícil. Se ha logrado mayor predicción de la vía aérea fácil. Es imposible en el servicio de urgencias determinar variables ideales que sean obtenibles, interpretables y confiables, ni se encuentran estudios locales sobre el tema. El manejo de la vía aérea difícil en urgencias se beneficia de la participación conjunta de especialidades como medicina de urgencias, anestesiología y cirugía, pero es necesario implementar estrategias de bajo costo distintas a la laringoscopia directa que han mostrado beneficio en el pronóstico del paciente. Abreviaturas: VAD, vía aérea difícil.
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Referencias
1. Omert L, Yeaney W, Mizikowski S, Protetch J. Role of the emergency medicine physician in airway management of the trauma patient. J Trauma. 2001; 51(6):1065-8.
2. Walls RM, Brown CA, Bair AE, Pallin DJ ; NEAR II Investigators. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med. 2011;41(4):347-54.
3. Smally AJ, Nowicki TA. Manejo de la vía aérea difícil. Emergencias. 2011;23(6):479-85.
4. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesiology. 2003; 98(5):1269-77.
5. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the american society of anesthesiologists task force on management of the difficult airway. Anesthesiology. 2013; 118(2):251-70.
6. Pennsylvania Patient Safety Authority. Management of unanticipated difficult intubation. Pa Patient Saf Advis. 2010; 7(4):113-22.
7. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011; 114(1):42-8.
8. Bair AE, Olmsted K, Brown CA, Barker T, Pallin D, Walls RM. Assessment of the storz video macintosh laryngoscope for use in difficult airways: A human simulator study. Acad Emerg Med. 2010; 17(10):1134-7.
9. Ehrenfeld JM, Cassedy EA, Forbes VE, Mercaldo ND, Sandberg WS. Modified rapid sequence induction and intubation: a survey of United States current practice. Anesth Analg. 2012; 115(1):95-101.
10. Koerber JP, Roberts GE, Whitaker R, Thorpe CM. Variation in rapid sequence induction techniques: current practice in Wales. Anaesthesia. 2009; 64(1):54-9.
11. Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011; 68(14):1320-30.
12. Chavarría-Islas RA, Robles Benítez LA, Loria Castellanos J, Rocha Luna JM. Complicaciones agudas por intubación orotraqueal en un Servicio de Urgencias. Archivos de medicina de urgenc. de Méx. 2012; 4(1):20-5.
13. Cook TM, Woodall N, Harper J, Benger J, Project FNA. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011; 106(5):632-42.
14. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-54.
15. Sagarin MJ, Barton ED, Chng YM, Walls RM, Investigators NEAR. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005; 46(4):328-36.
16. Nishisaki A, Ferry S, Colborn S, DeFalco C, Dominguez T, Brown CA, et al. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med. 2012; 13(1):e5-10.
17. Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, et al. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010; 341:c5943.
18. Mora Mantilla M, Oulego Erroz I, Alonso Quintela S, Gautreaux Minaya S, Mata Zubillaga D, Rodríguez Blanco S. Uso de la ecografía en la comprobación de la intubación traqueal urgente en Pediatría: experiencia preliminar. Bol Pediatr. 2012; (52):152-9.
19. Barrado Muñoz L, Barroso Mantilla S, Patón Morales G, Sánchez Carro J. Capnografía, la evolución en la monitorización del paciente crítico. Zona TES. 2013; (1):16-23.
20. López Rabassa SI, De la Paz Estada C, Diez Sanchez YM, González Rodriguez GS, Díaz Mediondo M. Utilización del Gum Elastic Bougie por traqueostoma en urgencia ventilatoria. A propósito de un caso. Rev Mex Anest. 2013;36(2):119-22.
21. Reis L, Ferreira G, Marchi M, Bredy L. Bougie. Rev Bras Anestesiol. 2009; 59(5):618-23.
22. Asai T. Monitoring during difficult airway management. J Anesth. 2014; 28(1): 87-93.
23. Pérez Santos FJ, Hernández Salgado M, Díaz-Landeira J, Santana Domínguez M, Domínguez García P, Herrera García M. Efectividad del uso de predictores de vía aérea difícil en el área de urgencias. Emergencias. 2011; 23(4):293-8.
24. Basaranoglu G, Columb M, Lyons G. Failure to predict difficult tracheal intubation for emergency caesarean section. Eur J Anaesthesiol. 2010; 27(11):947-9.
25. Bonilla AJ. Evaluación de la vía aérea en el paciente crítico. Rev Col Anest. 2008; 36(1):39-44.
26. Dargin JM, Emlet LL, Guyette FX. The effect of body mass index on intubation success rates and complications during emergency airway management. Intern Emerg Med. 2013; 8(1):75-82.
27. Oriol Lopez SA, Luna Robledo EJ, Hernández Bernal CE, López Cardenas LK. ¿Qué representa mayor dificultad, la ventilación o la intubación en el paciente obeso?. Rev Mex Anest. 2014; 37(2):83-90.
28. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92(5):1229-36.
29. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002; 94(3):732-6.
30. Mirghassemi A, Soltani AE, Abtahi M. Evaluation of laryngoscopic views and related influencing factors in a pediatric population. Paediatr Anaesth. 2011; 21(6):663-7.
31. Qudaisat IY, Al-Ghanem SM. Short thyromental distance is a surrogate for inadequate head extension, rather than small submandibular space, when indicating possible difficult direct laryngoscopy. Eur J Anaesthesiol. 2011; 28(8):600-6.
32. Etezadi F, Ahangari A, Shokri H, Najafi A, Khajavi MR, Daghigh M, et al. Thyromental height: a new clinical test for prediction of difficult laryngoscopy. Anesth Analg. 2013; 117(6):1347-51.
33. Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008; 106(4):1132-6.
34. Fritscherova S, Adamus M, Dostalova K, Koutna J, Hrabalek L, Zapletalova J, et al. Can difficult intubation be easily and rapidly predicted?. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011; 155(2):165-71.
35. Sahin SH, Yilmaz A, Gunday I, Kargi M, Sut N, Taskinalp O, et al. Using temporomandibular joint mobility to predict difficult tracheal intubation. J Anesth. 2011; 25(3):457-61.
36. Orozco Díaz É, Álvarez Rios JJ, Arceo Díaz JL, Ornelas Aguirre JM. Predicción de intubación difícil mediante escalas devaloración de la vía aérea. Cir Cir. 2010; 78(5):393-9.
37. Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med. 2004; 44(4):307-13.
38. Meléndez HJ, Leal D, Ramírez D. Concordancia de la evaluación objetiva y subjetiva en la predicción y hallazgo de vía aérea difícil. Rev Col Anest. 2010; 38(1):34-49.
39. Adhikari S, Zeger W, Schmier C, Crum T, Craven A, Frrokaj I, et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med. 2011;18 (7):754-8.
40. Sánchez Morillo J, Estruch Perez MJ, Hernández Cardiz MJ, Tamarit Conejeros JM, Gómez L, Richart Aznar M. La laringoscopia indirecta mediante endoscopio rígido de 70° como valor predictivo de la dificultad de visión de la laringe. Acta Otorrinolaringol Esp. 2012; 63(4):272-9.
41. Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med. 2014; 9(1):93-8.
42. Levitan RM. Design rationale and intended use of a short optical stylet for routine fiberoptic augmentation of emergency laryngoscopy. Am J Emerg Med. 2006; 24 (4):490-5.
43. Combes X, Dumerat M, Dhonneur G. Emergency gum elastic bougie-assisted tracheal intubation in four patients with upper airway distortion. Can J Anaesth. 2004; 51(10):1022-4.
44. Almaraz Ibarra M, López Garces VM, Amador Licona N, Pérez Aguilara R. Dificultad de la intubación con o sin espejo en la hoja del laringoscopio. Rev Med Inst Mex Seguro Soc. 2014; 52(1):60-4.
45. Botana M, Fernández Villar A, Leiro V, Represas C, Méndez A, Piñeiro L. Intubación traqueal guiada por fibrobroncoscopio en pacientes con vía aérea difícil. Factores predictores del resultado. Med Intensiva. 2009; 33(2):68-73.
46. Rodrigues AJ, Scordamaglio PR, Palomino AM, De Oliveira EQ, Jacomelli M, Figueiredo VR. Difficult airway intubation with flexible bronchoscope. Rev. Bras. Anestesiol. 2013; 63(4):358-61.
47. Sakles JC, Mosier J, Patanwala AE, Dicken J. Improvement in GlideScope® Video Laryngoscopy performance over a seven-year period in an academic emergency department. Intern Emerg Med. 2014; 9(7):789-94.
48. Dexheimer Neto FL, Stormovski JM, Tabajara Raupp AC, da Silva Townsend R, Santos Neres F, Viegas Cremonese R. Use of a homemade introducer guide (bougie) for intubation inemergency situation in patients who present with difficult airway:a case series. Braz J Anesthesiol. In press 2014.
49. Nashat Beshey B, Abdallah Helmy T, Samir Asaad H, Mostafa Ibrahim E. Emergency percutaneous tracheotomy in failed intubation. Egypt J Chest Dis Tuberc. 2014; 63(4):939-45.
50. Helm M, Hossfeld B, Jost C, Lampl L, Böckers T. Emergency cricothyroidotomy performed by inexperienced clinicians--surgical technique versus indicator-guided puncture technique. Emerg Med J. 2013; 30(8):646-9.
51. Duque Sierra LF. Intubación digital para el manejo de la vía aérea fallida en el servicio de urgencias. CES Med. 2011; 25(2):193-202.
52. Wong E, Ng YY. The difficult airway in the emergency department. Int J Emerg Med. 2008; 1(2):107-11.
2. Walls RM, Brown CA, Bair AE, Pallin DJ ; NEAR II Investigators. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med. 2011;41(4):347-54.
3. Smally AJ, Nowicki TA. Manejo de la vía aérea difícil. Emergencias. 2011;23(6):479-85.
4. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesiology. 2003; 98(5):1269-77.
5. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the american society of anesthesiologists task force on management of the difficult airway. Anesthesiology. 2013; 118(2):251-70.
6. Pennsylvania Patient Safety Authority. Management of unanticipated difficult intubation. Pa Patient Saf Advis. 2010; 7(4):113-22.
7. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011; 114(1):42-8.
8. Bair AE, Olmsted K, Brown CA, Barker T, Pallin D, Walls RM. Assessment of the storz video macintosh laryngoscope for use in difficult airways: A human simulator study. Acad Emerg Med. 2010; 17(10):1134-7.
9. Ehrenfeld JM, Cassedy EA, Forbes VE, Mercaldo ND, Sandberg WS. Modified rapid sequence induction and intubation: a survey of United States current practice. Anesth Analg. 2012; 115(1):95-101.
10. Koerber JP, Roberts GE, Whitaker R, Thorpe CM. Variation in rapid sequence induction techniques: current practice in Wales. Anaesthesia. 2009; 64(1):54-9.
11. Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011; 68(14):1320-30.
12. Chavarría-Islas RA, Robles Benítez LA, Loria Castellanos J, Rocha Luna JM. Complicaciones agudas por intubación orotraqueal en un Servicio de Urgencias. Archivos de medicina de urgenc. de Méx. 2012; 4(1):20-5.
13. Cook TM, Woodall N, Harper J, Benger J, Project FNA. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011; 106(5):632-42.
14. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-54.
15. Sagarin MJ, Barton ED, Chng YM, Walls RM, Investigators NEAR. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005; 46(4):328-36.
16. Nishisaki A, Ferry S, Colborn S, DeFalco C, Dominguez T, Brown CA, et al. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med. 2012; 13(1):e5-10.
17. Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, et al. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010; 341:c5943.
18. Mora Mantilla M, Oulego Erroz I, Alonso Quintela S, Gautreaux Minaya S, Mata Zubillaga D, Rodríguez Blanco S. Uso de la ecografía en la comprobación de la intubación traqueal urgente en Pediatría: experiencia preliminar. Bol Pediatr. 2012; (52):152-9.
19. Barrado Muñoz L, Barroso Mantilla S, Patón Morales G, Sánchez Carro J. Capnografía, la evolución en la monitorización del paciente crítico. Zona TES. 2013; (1):16-23.
20. López Rabassa SI, De la Paz Estada C, Diez Sanchez YM, González Rodriguez GS, Díaz Mediondo M. Utilización del Gum Elastic Bougie por traqueostoma en urgencia ventilatoria. A propósito de un caso. Rev Mex Anest. 2013;36(2):119-22.
21. Reis L, Ferreira G, Marchi M, Bredy L. Bougie. Rev Bras Anestesiol. 2009; 59(5):618-23.
22. Asai T. Monitoring during difficult airway management. J Anesth. 2014; 28(1): 87-93.
23. Pérez Santos FJ, Hernández Salgado M, Díaz-Landeira J, Santana Domínguez M, Domínguez García P, Herrera García M. Efectividad del uso de predictores de vía aérea difícil en el área de urgencias. Emergencias. 2011; 23(4):293-8.
24. Basaranoglu G, Columb M, Lyons G. Failure to predict difficult tracheal intubation for emergency caesarean section. Eur J Anaesthesiol. 2010; 27(11):947-9.
25. Bonilla AJ. Evaluación de la vía aérea en el paciente crítico. Rev Col Anest. 2008; 36(1):39-44.
26. Dargin JM, Emlet LL, Guyette FX. The effect of body mass index on intubation success rates and complications during emergency airway management. Intern Emerg Med. 2013; 8(1):75-82.
27. Oriol Lopez SA, Luna Robledo EJ, Hernández Bernal CE, López Cardenas LK. ¿Qué representa mayor dificultad, la ventilación o la intubación en el paciente obeso?. Rev Mex Anest. 2014; 37(2):83-90.
28. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92(5):1229-36.
29. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002; 94(3):732-6.
30. Mirghassemi A, Soltani AE, Abtahi M. Evaluation of laryngoscopic views and related influencing factors in a pediatric population. Paediatr Anaesth. 2011; 21(6):663-7.
31. Qudaisat IY, Al-Ghanem SM. Short thyromental distance is a surrogate for inadequate head extension, rather than small submandibular space, when indicating possible difficult direct laryngoscopy. Eur J Anaesthesiol. 2011; 28(8):600-6.
32. Etezadi F, Ahangari A, Shokri H, Najafi A, Khajavi MR, Daghigh M, et al. Thyromental height: a new clinical test for prediction of difficult laryngoscopy. Anesth Analg. 2013; 117(6):1347-51.
33. Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008; 106(4):1132-6.
34. Fritscherova S, Adamus M, Dostalova K, Koutna J, Hrabalek L, Zapletalova J, et al. Can difficult intubation be easily and rapidly predicted?. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011; 155(2):165-71.
35. Sahin SH, Yilmaz A, Gunday I, Kargi M, Sut N, Taskinalp O, et al. Using temporomandibular joint mobility to predict difficult tracheal intubation. J Anesth. 2011; 25(3):457-61.
36. Orozco Díaz É, Álvarez Rios JJ, Arceo Díaz JL, Ornelas Aguirre JM. Predicción de intubación difícil mediante escalas devaloración de la vía aérea. Cir Cir. 2010; 78(5):393-9.
37. Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med. 2004; 44(4):307-13.
38. Meléndez HJ, Leal D, Ramírez D. Concordancia de la evaluación objetiva y subjetiva en la predicción y hallazgo de vía aérea difícil. Rev Col Anest. 2010; 38(1):34-49.
39. Adhikari S, Zeger W, Schmier C, Crum T, Craven A, Frrokaj I, et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med. 2011;18 (7):754-8.
40. Sánchez Morillo J, Estruch Perez MJ, Hernández Cardiz MJ, Tamarit Conejeros JM, Gómez L, Richart Aznar M. La laringoscopia indirecta mediante endoscopio rígido de 70° como valor predictivo de la dificultad de visión de la laringe. Acta Otorrinolaringol Esp. 2012; 63(4):272-9.
41. Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med. 2014; 9(1):93-8.
42. Levitan RM. Design rationale and intended use of a short optical stylet for routine fiberoptic augmentation of emergency laryngoscopy. Am J Emerg Med. 2006; 24 (4):490-5.
43. Combes X, Dumerat M, Dhonneur G. Emergency gum elastic bougie-assisted tracheal intubation in four patients with upper airway distortion. Can J Anaesth. 2004; 51(10):1022-4.
44. Almaraz Ibarra M, López Garces VM, Amador Licona N, Pérez Aguilara R. Dificultad de la intubación con o sin espejo en la hoja del laringoscopio. Rev Med Inst Mex Seguro Soc. 2014; 52(1):60-4.
45. Botana M, Fernández Villar A, Leiro V, Represas C, Méndez A, Piñeiro L. Intubación traqueal guiada por fibrobroncoscopio en pacientes con vía aérea difícil. Factores predictores del resultado. Med Intensiva. 2009; 33(2):68-73.
46. Rodrigues AJ, Scordamaglio PR, Palomino AM, De Oliveira EQ, Jacomelli M, Figueiredo VR. Difficult airway intubation with flexible bronchoscope. Rev. Bras. Anestesiol. 2013; 63(4):358-61.
47. Sakles JC, Mosier J, Patanwala AE, Dicken J. Improvement in GlideScope® Video Laryngoscopy performance over a seven-year period in an academic emergency department. Intern Emerg Med. 2014; 9(7):789-94.
48. Dexheimer Neto FL, Stormovski JM, Tabajara Raupp AC, da Silva Townsend R, Santos Neres F, Viegas Cremonese R. Use of a homemade introducer guide (bougie) for intubation inemergency situation in patients who present with difficult airway:a case series. Braz J Anesthesiol. In press 2014.
49. Nashat Beshey B, Abdallah Helmy T, Samir Asaad H, Mostafa Ibrahim E. Emergency percutaneous tracheotomy in failed intubation. Egypt J Chest Dis Tuberc. 2014; 63(4):939-45.
50. Helm M, Hossfeld B, Jost C, Lampl L, Böckers T. Emergency cricothyroidotomy performed by inexperienced clinicians--surgical technique versus indicator-guided puncture technique. Emerg Med J. 2013; 30(8):646-9.
51. Duque Sierra LF. Intubación digital para el manejo de la vía aérea fallida en el servicio de urgencias. CES Med. 2011; 25(2):193-202.
52. Wong E, Ng YY. The difficult airway in the emergency department. Int J Emerg Med. 2008; 1(2):107-11.
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