I’m kicking off this year’s blog with an airway subject.
This is a review/follow up from the airway series last year, and it is a reminder for you to keep up with the regular drills for laryngoscopy, failed intubation, etc : )
* For those newly joined our C & C, we expect everyone on the red shift to be a solid basic airway specialist.
Please visit our airway series from last year.
Additionally, we hope most people, regardless of ATP, to be familiar with advanced airway equipment and the procedures.
Advanced airway management can only be delivered through good teamwork, and the lack of good assistant is certainly a strong contraindicaiton for RSI.
If you haven’t played with the airway roll in the ALS bag, please do so on the next shift. Ask your partner, ask ICPs to run through the process with you.
Direct laryngoscopy (DL) is the use of the laryngoscope to visualise the vocal cords under direct vision, usually to facilitate endotracheal intubation (ETI). Laryngoscope with video display is commonly known as video laryngoscopy (VL).
Let me start with “The best lecture on Airway Management–Ever?”
As described by Richard Levitan (The airway guru), the procedure involves four key steps:
(1) positioning and preparation
(2) epiglottoscopy (identification of the epiglottis)
(3) laryngeal exposure (identifying vocal cords hopefully..)
(4) delivery of the tube
Reference: Life in the Fast Lane – Direct Laryngoscopy
(1) Positioning and preparation
I hope to maintain high level of this skill set for many Red Shift crew regardless of ATP.
It is about practising the high quality basic airway care such as sniffing position, use of airway adjunct, proper BVM technique etc.
(2) epiglottoscopy & (3) laryngeal exposure
As mentioned before, delivery of the tube is an easy bit if you can master the process (2) and (3).
First pass success is important, as each subsequent attempts multiply the rate of desaturation and other adverse response to laryngoscopy. To increase the first pass success rate, many hospitals and EMS advocate the first attempt with bougie. St John medical directors are trusting guys and leaving the decision to each ICPs. Nevertheless, we are allowed only 2 (or 3 if certain) attempts and we must make some changes every attempt to improve the chance of successful intubation. No point in doing the same thing over.
I think the default for many ICPs is;
- Intubation with stylet
- Intubation with bougie
- If CICO (can’t intubate, can’t oxygenate) then surgical airway
Some advocate preloading of bougie sometimes described as “Kiwi Grip”
I’m not 100% convinced with the Kiwi Grip (or any other methods) as you still need to practice regularly to be solid with whatever the way you want to use the bougie.
See fantastic PHARM site for bougie related FOAM.
Dr Richard Levitan also has a website http://www.airwaycam.com/videos/ with fantastic learning resources with lots of fantastic laryngoscopy videos etc.
While laryngoscopy is ideally taught in the controlled environment by experienced educators such as anaesthetist, we currently have very limited access to the theatre and need to be proactive in getting as much high fidelity simulation practices as we can.
We must be pretty smooth and confident with the skill as in fact laryngoscopy is not the hard part especially with the new standard ETI = RSI. The hard part is to make the right the decision to intubate, resuscitate, and choose the right drug and dose. We will need multiple posts and C&Cs to keep improving the “the hard part”.
But for now, I leave this post with Laryngoscopy and Intubation SMACC Byte pearls – George Kovacs presents some pearls to help with laryngoscopy and intubation under pressure.