emDOCs Podcast – Episode 114: Airway/Intubation Mental Model

Model: Airway Meds have been pushed….. 60 second timer

• Breathe: 4 count in, 4 count hold, 4 count out, 4 count hold
  • To control our adrenaline surge
• Light Grip the laryngoscope (2 finger grip)
  • To avoid over aggressive tongue control
• Scissor the mouth open
• EVLI
  • Epiglottoscopy
    • Light grip following the curvature of the blade looking for landmarks as you go – uvula to the epiglottis
  • Valleculoscopy
    • Seat blade into vallecula and engage the hyoepiglottic ligament
  • Laryngoscopy
    • Now Switching to more force and lifting with proper mechanics
  • Intubation
    • Delivery of tube or bougie from right side of mouth (Keep view/blade in until tube passes )

Airway Mastery Goal

DASH-1A

• Definitive Airway Sans (Hypoxia, Hypotension, Hypercarbia) First Attempt
• Should aim for > 95% First Pass Success (FPS)
  • Things can be done on an individual and systems level to hit this
• Bad at estimating our rate
  • Difference between expert and average may be 1 in 10

Preparation

Pre-oxygenation

• HOB Elevated
• Either
  • Nasal Cannula (NC) 15 LPM + Non-Rebreather Mask (NRB) @ 15 LPM
  • NRB on High Flow (keep turning O2 up past 15LPM)
• If not @ 100% add PEEP with
  • NIPPV(CPAP/BiPAP)
  • BVM with a PEEP Valve @ 15 cm cm H2O
    • +NC @ 15 LPM
• Done for 3-4 min

PREOXI with NIV – Consider preoxygenation with NIPPV

BVM Set Up

• PEEP valve over expiration port
• ETCO2 waveform connected to bag and monitor

Apneic Oxygenation

• NC left on at 15 lpm to high flush rate throughout the entire intubation.
• Do not use ETCO2 nasal cannula for O2 delivery; every breath delivered in the emergency department should have waveform end tidal CO2

Positioning

• Ear hole at or above sternal line, face plane essentially parallel to the ceiling.

Tools

• OUR LEARNERS SHOULD BE UTILIZING SGVL WITH A BOUGIE ON A MAJORITY OF INTUBATIONS.
• Standard Geometry Video Laryngoscope (SGVL)
  • Instant feedback from attending
  • AVOID SUCCESS WITH BAD TECHNIQUE
  • Learning airway anatomy
  • Learn proper mechanics
  • Eventually doing direct with screen turned away
  • This path of SGVL on the screen, leads to increased FPS AND quicker mastery of DIRECT laryngoscopy
• Mac 3 over Mac 4 for appropriate pt
  • Allows better lifting force
• BOUGIE when using SGVL

Problem: I Can’t See Anything

Solution – Epiglottoscopy

• Go slow down the tongue/pull back and start again.
• Lead with suction for epiglottis camouflage
• Uvula will point the way

Problem: Can’t Expose the Cord

Solution – Valleculoscopy then Intubation

• Blade tip position matters more than force, be sure you are properly seated in vallecula + not deflecting the epiglottis
• Use external laryngeal manipulation to better set blade then use it to improve cord exposure

Then Laryngoscopy

• • Lift the head
  • Two Hand Lift
  • Use a Mac as a Miller

Problem: Delivery

Intubation Phase

• Anytime you are placing something in the mouth look at the mouth
• Problems on the screen? Look at the mouth
  • i.e. bougie going posterior, often deflecting off top teeth and then tongue, keep anterior
• Use and practice with the bougie
• Make tube straight to cuff
• Great view but can’t deliver the tube?
  • Not to close on the screen, 50/50 view with HAVL
• Ridged Stylet?
  • STOP, POP, DROP
• View mismatch between mouth and screen?
  • Bend the bougie
• STUCK?
  • Bougie past the cords
    • Pull back and turn right (clockwise), RINGS RIGHT
  • Tube at the cords
    • PULL BACK and turn left (counterclockwise), INLET Left
      • Make this part of microskills, give tube a quarter turn counterclockwise before passing through the cords to prevent

Resources/References

• EMCrit 372 – FoundStab Intubation SOP

EVLI-1

• EMCrit 236 – George Kovacs on EVLI Airway Incrementalization

EVLI-2

• EMCrit 253 – Kovacs Kata to Optimize a Failing Laryngoscopy Attempt

How to Learn and Teach Laryngoscopy

• EMCrit 347 – How to Teach & Learn Laryngoscopy
• EMCRIT- Driver How to Learn/Teach Laryngoscopy

Bougie Masterclass and More

• https://emcrit.org/emcrit/experts-guide-bougie/
• EMCrit 299 – Bougie Masterclass with George Kovacs
• EMCRIT Bougie Placement Videos
• EMCRIT Bougie Lessons From the Lit
• EMCrit Podcast 226 – Airway Update – Bougie and Positioning

Original Blog Post Inspiration

• Smart Laryngoscopy – The MedEDge Design Lab

First Pass Success:

• EMCRIT Airway CQI
• DASH-1A by Bill Hinckley, MD
• EMCRIT How to know if you are good at airway management
• Opinion Corner: Defining quality of care for airway management in emergencies
• The First Shot Is Often the Best Shot: First-Pass Intubation Success in Emergency Airway Management

More

• EMCrit Podcast 70 – Airway Management with Rich Levitan
• Podcast 142 – Airway Things I Learned from George Kovacs at the NYC Airway Course
• Richard levitan Own the Airway!
• EMCrit 3 – Laryngoscope as a Murder Weapon (LAMW) Series – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis
• EM Grand Rounds: Optimizing the DangerousER Airway in Dangerous Times
• Optimal GlideScope Hyperangulated Blade Positioning, Technique by Dr. Rich Levitan
• Video Laryngoscopy with a Mac-Style Blade Demonstrated by Dr. Rich Levitan, M.D.
• Surgical, Examination, & Educational Video Presentations
• AirwayOnDemand from Dr. Will Rosenblatt
• Epiglottoscopy
• Four Techniques for Handling the Omega-Shaped Epiglottis – Page 2 of 2
• Aime Airway: Home
• Paediatric Emergencies |