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Rogue Medic
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by Rogue Medic in Rogue Medic
I wrote about the start of the ALPS (Amiodarone, Lidocaine, Placebo Study) in 2012[1] and the results are now in.
... Read more »
Kudenchuk, P., Brown, S., Daya, M., Rea, T., Nichol, G., Morrison, L., Leroux, B., Vaillancourt, C., Wittwer, L., Callaway, C.... (2016) Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. New England Journal of Medicine. DOI: 10.1056/NEJMoa1514204
by Rogue Medic in Rogue Medic
The return of consciousness without the return of a pulse is still rare, but may be more common with our increased focus on high quality chest compressions. There is still no evidence that interrupting chest compressions, for anything other than defibrillation, improves outcomes.
Is this due to the consistency of the machine? Maybe. Maybe not. We do not have enough evidence to draw that conclusion.
Is this growing population really growing? Maybe. Maybe not. We do not have enough evidence ........ Read more »
Rice, D., Nudell, N., Habrat, D., Smith, J., & Ernest, E. (2016) CPR induced consciousness: It's time for sedation protocols for this growing population. Resuscitation. DOI: 10.1016/j.resuscitation.2016.02.013
Olaussen A, Shepherd M, Nehme Z, Smith K, Bernard S, & Mitra B. (2015) Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review. Resuscitation, 44-8. PMID: 25447435
Lilja G, Nilsson G, Nielsen N, Friberg H, Hassager C, Koopmans M, Kuiper M, Martini A, Mellinghoff J, Pelosi P.... (2015) Anxiety and depression among out-of-hospital cardiac arrest survivors. Resuscitation, 68-75. PMID: 26433116
by Rogue Medic in Rogue Medic
I decided to look for something I wrote that I have been wrong about. I thought about Masimo and their RAD-57. I had been very critical of Dr. Michael O’Reilly (then Executive Vice President of Masimo Corporation) for being an advocate of bad science, but he has been hired away by Apple.[1] He should be less dangerous with a telephone than he was with the RAD-57. At the time, he wrote –... Read more »
Weaver, L., Churchill, S., Deru, K., & Cooney, D. (2012) False Positive Rate of Carbon Monoxide Saturation by Pulse Oximetry of Emergency Department Patients. Respiratory Care. DOI: 10.4187/respcare.01744
Hampson NB, & Holm JR. (2015) Suicidal carbon monoxide poisoning has decreased with controls on automobile emissions. Undersea , 42(2), 159-64. PMID: 26094291
Roderique, J., Josef, C., Feldman, M., & Spiess, B. (2015) A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement. Toxicology, 45-58. DOI: 10.1016/j.tox.2015.05.004
Touger, M., Birnbaum, A., Wang, J., Chou, K., Pearson, D., & Bijur, P. (2010) Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement. Annals of Emergency Medicine, 56(4), 382-388. DOI: 10.1016/j.annemergmed.2010.03.041
O'Reilly, M. (2010) Performance of the Rad-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement. Annals of Emergency Medicine, 56(4), 442-444. DOI: 10.1016/j.annemergmed.2010.08.016
by Rogue Medic in Rogue Medic
Why is progress so slow in resuscitation research? A lot of money and time went in to finding out which type of blood-letting ventilation works best – ignoring the absence of valid evidence that ventilation is better than no ventilation. Why not gamble with our patients?
In response to The Fatal Flaw in Trial of Continuous or Interrupted Chest Compressions during CPR,[1],[2] Kenny commented that –
there are many things in your blog that are not correct.[1]... Read more »
Nichol, G., Leroux, B., Wang, H., Callaway, C., Sopko, G., Weisfeldt, M., Stiell, I., Morrison, L., Aufderheide, T., Cheskes, S.... (2015) Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine, 2147483647. DOI: 10.1056/NEJMoa1509139
by Rogue Medic in Rogue Medic
This is not a study that has a valid control group to determine if there is any benefit from ventilation. There is no group that does not receive ventilations, so it is like a study of one type of blood-letting vs. another type of blood-letting with the researchers taking for granted that blood-letting does improve outcomes. That is not a problem if blood-letting actually improves outcomes.
Should we take it for granted that blood-letting improves outcomes and that the only hypothesis worth s........ Read more »
Nichol, G., Leroux, B., Wang, H., Callaway, C., Sopko, G., Weisfeldt, M., Stiell, I., Morrison, L., Aufderheide, T., Cheskes, S.... (2015) Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine, 2147483647. DOI: 10.1056/NEJMoa1509139
Alldredge BK,, Gelb AM,, Isaacs SM,, Corry MD,, Allen F,, Ulrich S,, Gottwald MD,, O’Neil N,, Neuhaus JM,, Segal MR,.... (2001) A Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital Status Epilepticus. New England Journal of Medicine, 345(25), 1860-1860. DOI: 10.1056/NEJM200112203452521
by Rogue Medic in Rogue Medic
The new ACLS guidelines are out. How bad is the evidence?
The short answer – The Advanced Cardiac Life Support guidelines could be worse.
How does the American Heart Association determine that a recommendation is not beneficial?... Read more »
Morrison LJ, Gent LM, Lang E, Nunnally ME, Parker MJ, Callaway CW, Nadkarni VM, Fernandez AR, Billi JE, Egan JR.... (2015) Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 132(18 Suppl 2). PMID: 26472990
Lawrence, G. (2002) Tobacco smoke enemas. The Lancet, 359(9315), 1442. DOI: 10.1016/S0140-6736(02)08339-3
by Rogue Medic in Rogue Medic
We like to give treatments that produce results that we can see and logically attribute to the treatments we gave.
We like to give IV (IntaVenous) furosemide (Lasix – frusemide in Commonwealth countries) for CHF (Congestive Heart Failure).
1. The patient had CHF.
2. I gave IV furosemide.
3. The patient produced urine.... Read more »
Figueras J, & Weil MH. (1978) Blood volume prior to and following treatment of acute cardiogenic pulmonary edema. Circulation, 57(2), 349-55. PMID: 618625
Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine TB, & Cohn JN. (1985) Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. Annals of internal medicine, 103(1), 1-6. PMID: 2860833
Hoffman JR, & Reynolds S. (1987) Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema. Chest, 92(4), 586-93. PMID: 3115687
by Rogue Medic in Rogue Medic
Is 50% dextrose as good as 10% dextrose for treating symptomatic hypoglycemia?
If the patient is disoriented, but becomes oriented before the full dose of dextrose is given, is it appropriate to continue to treat the patient as if the patient were still disoriented? If your protocols require you to keep giving dextrose, do the same protocols require you to keep giving opioids after the pain is relieved? Is there really any difference?
50% dextrose has problems.... Read more »
Kiefer MV, Gene Hern H, Alter HJ, & Barger JB. (2014) Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehospital and disaster medicine, 29(2), 190-4. PMID: 24735872
Levy SB, & Rosh AJ. (2006) Images in emergency medicine. Dextrose extravasation causing skin necrosis. Annals of emergency medicine, 48(3). PMID: 16934641
by Rogue Medic in Rogue Medic
There are several news articles today criticizing a study because the patients might be deprived of a drug that has not been adequately studied in humans. This criticism is coming from journalists – the people who publicized the fraudulent vaccines research by Andrew Wakefield, who was trying to sell his competing vaccine and was being paid to produce negative research by lawyers suing the vaccine companies.[1]
The real controversy is that this untested drug became the standard of care ........ Read more »
Larabee TM, Liu KY, Campbell JA, & Little CM. (2012) Vasopressors in cardiac arrest: a systematic review. Resuscitation, 83(8), 932-9. PMID: 22425731
Woodhouse SP, Cox S, Boyd P, Case C, & Weber M. (1995) High dose and standard dose adrenaline do not alter survival, compared with placebo, in cardiac arrest. Resuscitation, 30(3), 243-9. PMID: 8867714
Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, & Holmberg S. (1995) Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?. Resuscitation, 29(3), 195-201. PMID: 7667549
Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP.... (2007) Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Annals of emergency medicine, 50(6), 635-42. PMID: 17509730
Olasveengen, T., Sunde, K., Brunborg, C., Thowsen, J., Steen, P., & Wik, L. (2009) Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial. JAMA: The Journal of the American Medical Association, 302(20), 2222-2229. DOI: 10.1001/jama.2009.1729
Olasveengen TM, Wik L, Sunde K, & Steen PA. (2011) Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial. Resuscitation. PMID: 22115931
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, & Thompson PL. (2011) Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation, 82(9), 1138-43. PMID: 21745533
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, & Miyazaki S. (2012) Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 307(11), 1161-8. PMID: 22436956
Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, & Kai T. (2012) Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circulation journal : official journal of the Japanese Circulation Society, 76(7), 1639-45. PMID: 22481099
Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P.... (2012) Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium. Resuscitation. PMID: 22858552
Donnino, M., Salciccioli, J., Howell, M., Cocchi, M., Giberson, B., Berg, K., Gautam, S., Callaway, C., & , . (2014) Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ, 348(may20 2). DOI: 10.1136/bmj.g3028
Callaham M, Madsen CD, Barton CW, Saunders CE, & Pointer J. (1992) A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA : the journal of the American Medical Association, 268(19), 2667-72. PMID: 1433686
Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, & Jastremski M. (1992) A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. The New England journal of medicine, 327(15), 1051-5. PMID: 1522841
Choux C, Gueugniaud PY, Barbieux A, Pham E, Lae C, Dubien PY, & Petit P. (1995) Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital. Resuscitation, 29(1), 3-9. PMID: 7784720
Gueugniaud PY, Mols P, Goldstein P, Pham E, Dubien PY, Deweerdt C, Vergnion M, Petit P, & Carli P. (1998) A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group. The New England journal of medicine, 339(22), 1595-601. PMID: 9828247
Vandycke C, & Martens P. (2000) High dose versus standard dose epinephrine in cardiac arrest - a meta-analysis. Resuscitation, 45(3), 161-6. PMID: 10959014
Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, & Dickinson GE. (1992) High-dose epinephrine in adult cardiac arrest. The New England journal of medicine, 327(15), 1045-50. PMID: 1522840
Callaway, C. (2012) Questioning the Use of Epinephrine to Treat Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1198. DOI: 10.1001/jama.2012.313
by Rogue Medic in Rogue Medic
There is an excellent review article by Dr. Bentley Bobrow and Dr. Gordon Ewy on the best management of sudden cardiac arrest from the bystander to the ICU (Intensive Care Unit).
They point out something that we tend to resist learning. Cardiac arrest that is not due to respiratory causes does not need respiratory treatment. A person who is unresponsive and gasping is exhibiting signs of cardiac arrest, not signs of respiratory problems.... Read more »
Ewy, G., & Bobrow, B. (2014) Cardiocerebral Resuscitation: An Approach to Improving Survival of Patients With Primary Cardiac Arrest. Journal of Intensive Care Medicine. DOI: 10.1177/0885066614544450
by Rogue Medic in Rogue Medic
This study is interesting for several reasons.
In a system that claims excellence, the most consistent way to identify the study group is by documentation of a protocol violation - but it is not intended as a study of protocol violations.
This may hint at some benefit from epinephrine (Adrenaline in Commonwealth countries), but that would require some study and we just don't study epinephrine. We only make excuses for not studying epinephrine.
The atropine results suggest that the ........ Read more »
Roberts, J. (2011) InFocus: Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions. Emergency Medicine News, 33(10), 16-18. DOI: 10.1097/01.EEM.0000406945.05619.ca
Koller, A., Salcido, D., Callaway, C., & Menegazzi, J. (2014) Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest. Resuscitation. DOI: 10.1016/j.resuscitation.2014.05.036
by Rogue Medic in Rogue Medic
This happens many times every day. A patient falls and may have hit her head, but there is no change from her normal mental status. To complicate matter, she takes an anticoagulant.
There are no clear signs of serious trauma. so should we automatically go to the trauma center?
What can help us decide?... Read more »
Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, & Jeanmonod D. (2014) Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury. The American journal of emergency medicine. PMID: 24929771
by Rogue Medic in Rogue Medic
On the MedicCast, Jamie Davis interviews Roy Shaw of SUMO about a method of remote CPR certification for health care providers.
"The Single Use Manikin Option, or SUMO™, is an AHA-compliant way of getting certified in CPR completely online.[1]"
What different ways of dealing with certification/recertification problems should we use?... Read more »
Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. (2011) Low-Dose, High-Frequency CPR Training Improves Skill Retention of In-Hospital Pediatric Providers. PEDIATRICS, 128(1). DOI: 10.1542/peds.2010-2105d
by Rogue Medic in Rogue Medic
I have been very critical of plans to have first responders treat people they suspect of having a heroin (or other) opioid overdose with naloxone.
Would first responders be safer with fentanyl?
It is not really the same question, but it does highlight the differences and why I think fentanyl is safer. The patient will be seen by someone more likely to recognize when the treatment is inappropriate. This study looked at IN (IntraNasal) fentanyl given by basic EMTs prior to transport to the E........ Read more »
Krauss, W., Shah, S., Shah, S., & Thomas, S. (2011) Fentanyl in the Out-of-Hospital Setting: Variables Associated with Hypotension and Hypoxemia. The Journal of Emergency Medicine, 40(2), 182-187. DOI: 10.1016/j.jemermed.2009.02.009
Karlsen AP, Pedersen DM, Trautner S, Dahl JB, & Hansen MS. (2014) Safety of intranasal fentanyl in the out-of-hospital setting: a prospective observational study. Annals of emergency medicine, 63(6), 699-703. PMID: 24268523
by Rogue Medic in Rogue Medic
If we are going to give epinephrine to patients with rhythms that are not shockable (PEA [Pulseless Electrical Activity] or Asystole), it appears that patients receiving epinephrine earlier have better outcomes than patients who receive epinephrine later in the hospital in the less acute care settings.
Does this mean that patients who receive epinephrine have better outcomes than patients who do not receive epinephrine?
We remain willfully ignorant of the answer to that question.
... Read more »
Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A.... (2010) Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14(3), 355-60. PMID: 20388032
Donnino, M., Salciccioli, J., Howell, M., Cocchi, M., Giberson, B., Berg, K., Gautam, S., Callaway, C., & , . (2014) Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ, 348(may20 2). DOI: 10.1136/bmj.g3028
by Rogue Medic in Rogue Medic
Continuing from Part I, Part II, and Part III in response to what I wrote about the failure of the LUCAS,[1] Sean continues with -
"Another issue I have with this data, is that it doesn’t address the following variables:
Down time
Whether or not bystander CPR was performed
Medications used
Whether or not an advanced airway was placed
Length of resuscitation"... Read more »
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R.... (2014) Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311(1), 53-61. PMID: 24240611
Rubertsson S, Silfverstolpe J, Rehn L, Nyman T, Lichtveld R, Boomars R, Bruins W, Ahlstedt B, Puggioli H, Lindgren E.... (2013) The study protocol for the LINC (LUCAS in cardiac arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scandinavian journal of trauma, resuscitation and emergency medicine, 5. PMID: 23351178
by Rogue Medic in Rogue Medic
Sean continues to explain how the machine that does not improve outcomes allows him to provide other 'treatments' that do not improve outcomes.
I continue to point out the problems with his excuses.
.... Read more »
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R.... (2014) Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311(1), 53-61. PMID: 24240611
Larabee TM, Liu KY, Campbell JA, & Little CM. (2012) Vasopressors in cardiac arrest: a systematic review. Resuscitation, 83(8), 932-9. PMID: 22425731
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, & Miyazaki S. (2012) Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 307(11), 1161-8. PMID: 22436956
Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, & Kai T. (2012) Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circulation journal : official journal of the Japanese Circulation Society, 76(7), 1639-45. PMID: 22481099
Thel MC, Armstrong AL, McNulty SE, Califf RM, & O'Connor CM. (1997) Randomised trial of magnesium in in-hospital cardiac arrest. Duke Internal Medicine Housestaff. Lancet, 350(9087), 1272-6. PMID: 9357406
Allegra J, Lavery R, Cody R, Birnbaum G, Brennan J, Hartman A, Horowitz M, Nashed A, & Yablonski M. (2001) Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting. Resuscitation, 49(3), 245-9. PMID: 11719117
Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, & Walsh T. (1999) Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. The New England journal of medicine, 341(12), 871-8. PMID: 10486418
by Rogue Medic in Rogue Medic
Do we do too many 12 lead ECGs on patients who do not have chest pain?
This is something that some people worry about.
Save the electrodes!
Those poor little electrodes are being abused!
Are electrodes being abused?... Read more »
Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, & Glickman LT. (2012) Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. American heart journal, 163(3), 372-82. PMID: 22424007
by Rogue Medic in Rogue Medic
We love gadgets in EMS.
Dr. Bryan Bledsoe tells us that if we paint it orange and put a star of life on it, we can sell any product for a lot more money.
How much would you pay to not improve outcomes?
$10,000.00?
$20,000.00?
$30,000.00?
$40,000.00?
$50,000.00?... Read more »
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R.... (2014) Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311(1), 53-61. PMID: 24240611
by Rogue Medic in Rogue Medic
Continuing from Part I of a paper that could, at best, be described as a convenience sample, since a quarter of patients were excluded from randomization because of attending physician bias.
What were the authors assuming when comparing GVL (GlideScope Video Laryngoscope) with DL (Direct Laryngoscopy) for intubation?... Read more »
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM. (2013) Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75(2), 212-9. PMID: 23823612
Lee A, Fan LT, Gin T, Karmakar MK, & Ngan Kee WD. (2006) A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesthesia and analgesia, 102(6), 1867-78. PMID: 16717341
Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L'hermite J, Wetterslev J, & Danish Anaesthesia Database. (2011) Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British journal of anaesthesia, 107(5), 659-67. PMID: 21948956
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