Epidural blood patch is the gold standard treatment for dural puncture headache.

study, 92% of patients received a neuromuscular blocker and fewer than 1% required more than two attempts at tracheal intubation. There is a clear link between multiple attempts at intubation and development of complications, some of which are life-threatening. In a study of 2833 intubations in critically ill patients, neuromuscular block was used in only 20% of intubations, and in 17% only topical anaesthesia or nothing was used. One in 10 patients required more than two attempts at tracheal intubation; complications were significantly more common in this group: hypoxaemia (70% vs 11.8%), oesophageal intubation (51% vs ,5%), cardiac arrest (11% vs 0.7%), regurgitation (22% vs 1.9%), and aspiration of gastric contents (13% vs 0.8%). In 3423 out-of-theatre intubations, neuromuscular block was used in 63% of the 144 patients who developed significant complications compared with 73% of those who did not; multiple attempts at intubation and poor laryngoscopic views were more common in patients not given a neuromuscular blocker (.2 attempts at intubation 16% vs 2%; C&L grade 3 or 4 20% vs 8.7%). A further study found attending physicians were more likely to use neuromuscular block, with fewer resulting complications, than junior doctors. The NAP4 project which reported major complications of airway management found that failed intubation, difficult or delayed intubation, and ‘can’t intubate, can’t ventilate’ accounted for 39% of all events, and 53% of events which occurred in the intensive care unit (ICU). In that report, several events in the ICU and the emergency department were managed by doctors who would not be expected to have airway expertise; indeed, ‘education and training’ was considered a causal or contributory factor in 58% of ICU cases. In summary, we believe that unsupervised junior trainees with little airway expertise should not be the first responders for airway management in the critically ill patient, and that when used by doctors with airway expertise, neuromuscular blockers contribute to fewer multiple attempts at tracheal intubation and fewer life-threatening complications.