Intubating style - what's yours?

[pinipig523]

So I was trained to intubate by several attendings when I was a resident a few years ago... No one technique was really forced on me so I just kinda worked out which one made most sense.

Towards the end of my training I ended up just doing the "insert the MAC4 down the middle of the tongue and slowly crawl down to the post pharynx until you start seeing structures you can identify, then move to the vallecula and pull up until you see cords" technique. It was simple and it got the job done most of the time.

However, I began to note that the more anterior or difficult patients weren't the easiest to tube. So I began to really develop a different technique from my usual... I began to sweep the tongue... Not overly so but just enough that I would insert the MAC4 blade to the right of the mouth and slowly crawl until I see structures.

Without a large tongue taking up space anterior to the blade, airways just seem significantly (knock on wood) easier. Things are much clearer and the cords are in a much better position. There is less lifting, tilting, manipulating of the head.

My other technique is also external laryngeal manipulation... Just move the cords to the right spot and have someone hold it there.

Another adjuvant is to tilt the head back by using the patient's forehead as a manipulation point (push on the forehead).

What's your technique? And if you haven't mastered the tongue sweep... You should try it. It's so much better than the simple and rudimentary go down the middle of the tongue/mouth method. No wonder anesthesia harp on us to sweep the tongue.

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[Daiphon]

So I was trained to intubate by several attendings when I was a resident a few years ago... No one technique was really forced on me so I just kinda worked out which one made most sense.

Towards the end of my training I ended up just doing the "insert the MAC4 down the middle of the tongue and slowly crawl down to the post pharynx until you start seeing structures you can identify, then move to the vallecula and pull up until you see cords" technique. It was simple and it got the job done most of the time.

However, I began to note that the more anterior or difficult patients weren't the easiest to tube. So I began to really develop a different technique from my usual... I began to sweep the tongue... Not overly so but just enough that I would insert the MAC4 blade to the right of the mouth and slowly crawl until I see structures.

Without a large tongue taking up space anterior to the blade, airways just seem significantly (knock on wood) easier. Things are much clearer and the cords are in a much better position. There is less lifting, tilting, manipulating of the head.

My other technique is also external laryngeal manipulation... Just move the cords to the right spot and have someone hold it there.

Another adjuvant is to tilt the head back by using the patient's forehead as a manipulation point (push on the forehead).

What's your technique? And if you haven't mastered the tongue sweep... You should try it. It's so much better than the simple and rudimentary go down the middle of the tongue/mouth method. No wonder anesthesia harp on us to sweep the tongue.

I was always taught to sweep w/ Mac... Miller was midline; the Mac is designed to hold the tongue out of the way.

Mix this into bimanual technique and I've got a solid track record.

Sent from my DROID BIONIC using Tapatalk

 

[joeDO2]

I was always taught to sweep w/ Mac... Miller was midline; the Mac is designed to hold the tongue out of the way.

Mix this into bimanual technique and I've got a solid track record.

Sent from my DROID BIONIC using Tapatalk

yup, sweep. bimanual technique if needed. also helps to have an assistant pull the corner of the mouth to increase view. i think the most appreciable difference is in the optimal positioning of the head... ie ear to sternal notch, face parallel to ceiling, ramp if needed with blankets/pillows

 

[Groove]

My recipe is Mac 4, sweep, bimanual and having everything available in the room for a really bad scenario. I've also found it's 90% positioning. Pt positioning, equipment positioning and operator positioning.

Finesse and manipulative mastery is a bit more difficult to articulate as it's dependent on so many variables.

I've had enough sphincter tightening experiences to walk into every one expecting it to be the worst one yet. I've carried an LMA into almost every intubation after an intern cric experience where the anesthesiologist gave me that tip... He also told me that I'd be an expert...when I knew I'd never be an expert. Really stuck... I go into virtually every one with multiple back ups available even though I very rarely (knock on wood) need them. Bougie and LMA are my usual back up devices and I always have a mental check of where an #11 blade is located. I rarely need a glidescope or choose to use one but I like knowing that it's nearby. I also like knowing where all my (pick age) "crashing peds airway" equipment is located and knowing that I'll have everything I could possibly need in the situation. When I used to moonlight as a resident, my first shift at a new hospital... I'd drive RT and nurses nuts because I'd break out all the airway stuff and re-arrange, making sure I had everything I wanted. I used to fly and work in another state quite a bit and routinely carried a bougie in my backpack because they didn't have one at these tiny places, lol. I'm surprised it never got pulled out.

Anyway, got off on a tangent there...

For me... Mac --> bougie/Miller --> Glidescope/LMA --> further down the yellow brick road.

I consider this area of expertise to be a real art with limitless room for additional learning and mastery. I've found that just when I get cocky and feel as if I can't fail, inevitably my next pt is an airway nightmare. It's like karma or something.

Also, I have the utmost respect for our anesthesia colleagues. I can remember one case last year where I paged them prior to even attempting an intubation on a pt that as I sat there looking at them...realized that I had zero room for error and that any error at all would be a catastrophic airway failure and emergent cric. I let go of my ego in that situation and did what was best for the pt. It doesn't happen often, but I think part of being good is to realize when you need backup.

 

[pinipig523]

Yeah, I never intubate without a bougie next to me or an 11 blade in my pocket.

Groove - I think you're right, I should try to have an LMA next to me as well.

And I think you guys are right, articulating the little minutias of getting that blade in there is difficult - but I think (from my experience), the sweep of the tongue and getting as much tissue away from being between the blade and the oral pharynx.... tongue sweep is crucial.

My protocol:
Mac4 -> Bougie -> Miller + Bougie -> Glidescope -> LMA -> Retry or cric or call anesthesia -> Sphincter.

 

[BLADEMDA]

Yeah, I never intubate without a bougie next to me or an 11 blade in my pocket.

Groove - I think you're right, I should try to have an LMA next to me as well.

And I think you guys are right, articulating the little minutias of getting that blade in there is difficult - but I think (from my experience), the sweep of the tongue and getting as much tissue away from being between the blade and the oral pharynx.... tongue sweep is crucial.

My protocol:
Mac4 -> Bougie -> Miller + Bougie -> Glidescope -> LMA -> Retry or cric or call anesthesia -> Sphincter.

Once you failed to intubate after several attempts followed by failure with the Glidescope my advice is page anesthesia stat and insert the LMA. Your job is to ventilate the patient by any means Necessary until backup arrives. Do not attempt to intubate again if you can ventilate via LMA or bag/mask. Nobody every died because of a failed intubation but rather because of failed ventilation. Multiple and multiple laryngoscopies by one or a variety of Attendings are ill-advised as you are increasing the trauma to the airway.

The LMA has saved thousands of lives since its invention by Dr. Brain. Please put your ego aside and just ventilate the patient until Anesthesia arrives on the scene. The patient and his/her family may thank you for this decision.

http://www.ncbi.nlm.nih.gov/pubmed/11165839

 

[BLADEMDA]

No large controlled studies have been done comparing the LMA with other emergency airway devices. Nor is it likely that any ever will be. The LMA's clinical record alone has proven it to be an invaluable device. The ability to provide safe anesthesia care was greatly increased with the in- troduction of the LMA. What is clear from multiple reports is that it has rescued many patients from a dire situation involving poor airways. This is true in all age groups from premature infants to elderly adults. Its excel- lent clinical record and simplicity demand its inclusion in any approach to the difficult airway as detailed by Benumof.19 It has improved our ability to handle difficult airways in unmeasurable ways and should be present in all anesthetizing locations.

http://felipeairway.sites.medinfo.u...ational-anesthesiology-clinics-2000-campo.pdf

 

[BLADEMDA]

http://www.asahq.org/For-Members/Pr... Management of the Difficult Airway 2013.ashx

Just look at page 7. SGA means Supraglottic airway (e.g. LMA)

 

[BLADEMDA]

Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room. There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (&#8804;2 versus >2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.


http://www.anesthesia-analgesia.org/content/99/2/607.full.pdf

 

[Arcan57]

Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room. There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (&#8804;2 versus >2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.


http://www.anesthesia-analgesia.org/content/99/2/607.full.pdf

Our literature actually suggests that the cut point for significant morbidity is at first-pass success. I honestly think hypoxia as an endpoint is somewhat fluffy (desatting to 89% for 5 sec vs. 40% for 5 minutes is not equivalent and I would argue that the cut-off for hypoxia doesn't correlate with measurable harm in most patients), but all of the others are pretty solidly in the negative column.

Acad Emerg Med. 2013 Jan;20(1):71-8. doi: 10.1111/acem.12055.

The importance of first pass success when performing orotracheal intubation in the emergency department.

Sakles JC, Chiu S, Mosier J, Walker C, Stolz U.


Source

Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA. [email protected]


Abstract


OBJECTIVES:

The goal of this study was to determine the association of first pass success with the incidence of adverse events (AEs) during emergency department (ED) intubations.

METHODS:

This was a retrospective analysis of prospectively collected continuous quality improvement data based on orotracheal intubations performed in an academic ED over a 4-year period. Following each intubation, the operator completed a data form regarding multiple aspects of the intubation, including patient and operator characteristics, method of intubation, device used, the number of attempts required, and AEs. Numerous AEs were tracked and included events such as witnessed aspiration, oxygen desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest. Multivariable logistic regression was used to assess the relationship between the primary predictor variable of interest, first pass success, and the outcome variable, the presence of one or more AEs, after controlling for various other potential risk factors and confounders.

RESULTS:

Over the 4-year study period, there were 1,828 orotracheal intubations. If the intubation was successful on the first attempt, the incidence of one or more AEs was 14.2% (95% confidence interval [CI] = 12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases requiring four or more attempts, the incidence of one or more AEs was 70.6% (95% CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than one attempt at tracheal intubation was a significant predictor of one or more AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63).

CONCLUSIONS:

When performing orotracheal intubation in the ED, first pass success is associated with a relatively small incidence of AEs. As the number of attempts increases, the incidence of AEs increases substantially.

 

[BLADEMDA]

Do you really think most Emergency Room Physicians are going to only attempt one laryngoscopy before the glidescope or LMA? While you can publish a one attempt at laryngoscopy study I seriously doubt that reflects real world practice. I use 3 scopes" myself before going to plan B. What do you do?

Most of the time if I fail to get the airway on the first attempt a change of the blade combined with better positioning and suction results in success on attempt 2. I only do an attempt 3 if I can see the posterior artynenoids which means a bougie should work. Glidescope would follow my attempt 2 or 3 then an LMA.
If the LMA worked in ventilating the patient I would perform a Fiberoptic intubation via the LMA.

This is my approach in the trauma bay for the typical trauma patient who needs an urgent intubation.
Of course, I do an RSI on trauma patients whenever possible.

My number one and 2 reasons for a failed laryngoscopy on the first attempt in the trauma bay are the following:

1. Very bloody airway with blood/secretions in the mouth
2. Poor positioning on the trauma table combined with the often too large cervical collar

Usually, repositioning and good suctioning results in success on attempt number 2 (if I couldn't see the cords well on attempt number 1).

 

[BLADEMDA]

Are some EM programs teaching residents to use the Glidescope first in every situation in the ER?


Display Settings:AbstractSend to:
J Emerg Med. 2012 Apr;42(4):400-5. doi: 10.1016/j.jemermed.2011.05.019. Epub 2011 Jul 14.
Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations.
Sakles JC, Mosier JM, Chiu S, Keim SM.
Source
Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA.
Abstract
BACKGROUND:
Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy.
OBJECTIVES:
To compare the success rates of GlideScope(®) (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations.
METHODS:
This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope(®) standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure.
RESULTS:
There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005.
CONCLUSION:
The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management.
Published by Elsevier Inc.

 

[deleted547339]

Are some EM programs teaching residents to use the Glidescope first in every situation in the ER?


Display Settings:AbstractSend to:
J Emerg Med. 2012 Apr;42(4):400-5. doi: 10.1016/j.jemermed.2011.05.019. Epub 2011 Jul 14.
Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations.
Sakles JC, Mosier JM, Chiu S, Keim SM.
Source
Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA.
Abstract
BACKGROUND:
Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy.
OBJECTIVES:
To compare the success rates of GlideScope(®) (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations.
METHODS:
This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope(®) standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure.
RESULTS:
There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005.
CONCLUSION:
The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management.
Published by Elsevier Inc.

I'll use it as a first line only when I think things could go south quickly. We are expected to start DL unless we suspect badness in a patient that we suspect will desat quickly. That ends up with about 90% DL.

 

[dotcb]

-message deleted-

 

[dotcb]

Originally Posted by BLADEMDA
"Are some EM programs teaching residents to use the Glidescope first in every situation in the ER?"


No - although there are 'airway experts' and evidence that would support VL as 1st attempt in most cases. There are vocal champions on both sides of the VL vs. DL debate, but most moderates know it doesn't pay to be a one trick pony.

 

[deleted109597]

Until every shop in the world has 100% accessible 100% reliable VL, then this is a bad plan.
You never can never perform something you don't learn. The overwhelming majority of EDs in the world don't have VL, or don't have it instantly available.

 

[pinipig523]

VL vs DL.... I think it's good to be proficient in both.

I still prefer DL just because I can get it done faster and I just feel more comfortable with it. Not sure why.

 

[BLADEMDA]

Until every shop in the world has 100% accessible 100% reliable VL, then this is a bad plan.
You never can never perform something you don't learn. The overwhelming majority of EDs in the world don't have VL, or don't have it instantly available.

I can see this situation as well: A patient needs an urgent intubation so the ER Physician goes to get his Glidescope which he uses for every intubation. He pushes the button to turn it on and the screen is all fuzzy. Somehow the camera or wire got damaged.
The ER Physician now has a look of total panic on his face as he hasn't performed a DL since Residency. That is not a good situation.

 

[Rendar5]

In residency I was taught to switch up between VL and DL for first attempts on a regular basis to keep my skills up.

 

[bougiecric]

"Has Video Laryngoscopy Killed the Direct Laryngoscope?"

http://emcrit.org/podcasts/has-video-laryngoscopy-killed-the-dl-star/

This is a debate between Dr. Weingart (ED physician -- pro DL) and Dr. Mayo (intensivist -- pro VL). I land squarely on the pro DL side.

 

[KYTNOH]

I move very quickly to a videoscope if my first attempt at DL reveals a difficult airway. If there's something that I can easily correct (positioning) then I'll do DL again, but if I think I'm going to have difficulty with it at all after the first look then I'll move to VL immediately. If there's an anticipated difficult airway then I'll go straight to VL, and I'll fairly regularly just pull out the VL to "play." The nurses and RTs love being able to see the anatomy. I'm still afraid to lose my DL skills as the VLs are not ubiquitous and there are definitely times where you can be put in an austere environment unexpectedly. There are also concerns I have with the occasional VERY bloody airway where I've got my laryngoscope and suction in the pharynx at the same time.

There's no reason why every ER in the US doesn't have a VL, and there's really no reason why every ALS ambulance in the country couldn't have a VL within the next 5 years. These things are becoming CHEAP. Our McGrath only cost $1200, and we weren't even buying in bulk. The disposable blades are only a few dollars, and may be cheaper in the long run when comparing them to traditional laryngoscopes that much be sterilized after each use.

 

[Xanthochromia]

"I can see this situation as well: A patient needs an urgent intubation so the ER Physician goes to get his Glidescope which he uses for every intubation. He pushes the button to turn it on and the screen is all fuzzy. Somehow the camera or wire got damaged.
The ER Physician now has a look of total panic on his face as he hasn't performed a DL since Residency. That is not a good situation."

This is silly. I have never seen or heard of such an occurrence. As hard as it may be to believe, the vast majority of intubations go very smoothly in emergency departments all across the country every day.

 

[Xanthochromia]

.

 

[gman33]

Any tips on the tongue sweep (or resources)?

Tongue control is still something that screws me up from time to time.
More so with DL.
VL pretty much never. Not sure if this is partly because VL I just go midline, where DL I try to go in on the right and sweep. Sometimes this is a bit of a cluster.
I think this is partly because I may go in a little far in and lose my landmarks.

 

[FLTDOC1]

I can see this situation as well: A patient needs an urgent intubation so the ER Physician goes to get his Glidescope which he uses for every intubation. He pushes the button to turn it on and the screen is all fuzzy. Somehow the camera or wire got damaged.
The ER Physician now has a look of total panic on his face as he hasn't performed a DL since Residency. That is not a good situation.

Not a good situation but not what I would remotely consider an airway emergency. Take a big breath and simply place a King LT or LMA, --problem temporarily solved. Any EM physician should be proficient in supraglottic airways and even the dreaded surgical airway

 

[pinipig523]

Any tips on the tongue sweep (or resources)?

Tongue control is still something that screws me up from time to time.
More so with DL.
VL pretty much never. Not sure if this is partly because VL I just go midline, where DL I try to go in on the right and sweep. Sometimes this is a bit of a cluster.
I think this is partly because I may go in a little far in and lose my landmarks.

There are several ways to sweep the tongue, but I found that simply starting with the handle pointed straight away from you instead of twisting the blade is simplest and most efficient way.

1. Just as you would go down the middle of the tongue, keep the blade handle straight away from you BUT enter the mouth through the right-most part of the mouth/lips.
2. Do it slow... go very slow. Don't go in too deep right away. Crawl down the post pharynx.
3. Use your free hand to wiggle the glottic region, get the glottis in view and have someone hold it there.
4. Get your blade either into the vallecula or cup the epiglottis, whichever you can do better in that particular situation.

Sweeping the tongue frees you from any more anterior tissue stuck between the blade and the glottic region... it is so much easier to intubate.

*Knock on wood*

Not a good situation but not what I would remotely consider an airway emergency. Take a big breath and simply place a King LT or LMA, --problem temporarily solved. Any EM physician should be proficient in supraglottic airways and even the dreaded surgical airway

With regards to LMAs... I know how to apply it blind, sometimes use a tongue depressor to aid the glide down.

However, have any of you pros used a MAC blade to help place the LMA down even better? Just a thought...

 

[fahimaz7]

Once you failed to intubate after several attempts followed by failure with the Glidescope my advice is page anesthesia stat and insert the LMA. Your job is to ventilate the patient by any means Necessary until backup arrives. Do not attempt to intubate again if you can ventilate via LMA or bag/mask. Nobody every died because of a failed intubation but rather because of failed ventilation. Multiple and multiple laryngoscopies by one or a variety of Attendings are ill-advised as you are increasing the trauma to the airway.

The LMA has saved thousands of lives since its invention by Dr. Brain. Please put your ego aside and just ventilate the patient until Anesthesia arrives on the scene. The patient and his/her family may thank you for this decision.

http://www.ncbi.nlm.nih.gov/pubmed/11165839

Just got done intubating a guy with bilateral paralyzed vocal cords. They were midline and fixed and he had a pre-intubation SaO2 of 66. Scary stuff. My backup prior to the intubation was bougie and LMA, neither of which would have really helped me if I would have failed the initial attempt (realized once I saw the cords on the c-mac). So glad I was able to get the tube through the cords and turned down the trachea.

 

[BLADEMDA]

47 percent of patents who could not be intubated with a glidescope were successfully intubated using DL.

Predictors for a failed intubation with the Glidescope:


Four preoperative predictors, including neck anatomy (P &#65533;&#65533; 0.002), TM distance (P &#65533;&#65533; 0.003), cervical motion (P &#65533;&#65533; 0.046), and institution (P &#65533;&#65533; 0.004), were found to be sig- nificantly associated with failed GVL intubation. Regarding neck pathology, patients with scar, radiation, or mass were more likely to have a failed GVL intubation compared with patients with normal neck anatomy (odds ratio: 4.39; 95% CI: 2.04, 9.46) and patients with thick neck (OR: 3.21; 95% CI: 1.37, 7.48). Patients with a shorter TM distance (less than 6 cm) were more likely to have a failed GVL intubation (OR: 2.53; 95% CI: 1.38, 4.64) compared with patients with a TM distance of more than 6 cm. In addition, patients with limited cervical motion (OR: 1.76; 95% CI: 1.01, 3.06) and those from UMHS (OR: 2.28; 95% CI: 1.30, 4.01) were also more likely to have a failed GVL intubation. The other tested variables&#8212;age, gender, body mass index, Mallampati score, and mouth opening&#8212;were not significantly associated with failed GVL intubation.

http://felipeairway.sites.medinfo.ufl.edu/files/2009/06/Glidescope-2010.pdf

 

[Rendar5]

Just got done intubating a guy with bilateral paralyzed vocal cords. They were midline and fixed and he had a pre-intubation SaO2 of 66. Scary stuff. My backup prior to the intubation was bougie and LMA, neither of which would have really helped me if I would have failed the initial attempt (realized once I saw the cords on the c-mac). So glad I was able to get the tube through the cords and turned down the trachea.

why wouldn't a bougie help? if you can get a tube past the cords, surely you could get a bougie past them. were they unbaggable?

 

[BLADEMDA]

Electrical failure of video laryngoscopes can and does happen as noted in the Anesthesiology literature. If you are relying on this device for 100 percent of all your intubations consider having at least 2 available at all times.

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=900785

A good discussion of the Glidescope and intubation tips.

 

[BLADEMDA]

Glidescope assisted Fiberoptic intubation. It works nicely when the Glidescope alone doesn't get the job done.

http://doylecv.homestead.com/GlideScopeAssistedFOBRev2.pdf

 

[gman33]

There are several ways to sweep the tongue, but I found that simply starting with the handle pointed straight away from you instead of twisting the blade is simplest and most efficient way.

1. Just as you would go down the middle of the tongue, keep the blade handle straight away from you BUT enter the mouth through the right-most part of the mouth/lips.
2. Do it slow... go very slow. Don't go in too deep right away. Crawl down the post pharynx.
3. Use your free hand to wiggle the glottic region, get the glottis in view and have someone hold it there.
4. Get your blade either into the vallecula or cup the epiglottis, whichever you can do better in that particular situation.

Sweeping the tongue frees you from any more anterior tissue stuck between the blade and the glottic region... it is so much easier to intubate.

*Knock on wood*



With regards to LMAs... I know how to apply it blind, sometimes use a tongue depressor to aid the glide down.

However, have any of you pros used a MAC blade to help place the LMA down even better? Just a thought...

thanks.
Just to clarify, are you going into the vallecula before sliding over midline?

 

[deleted109597]

this is silly. I have never seen or heard of such an occurrence. As hard as it may be to believe, the vast majority of intubations go very smoothly in emergency departments all across the country every day.

 

[xaelia]

My usual intubating style is to stand off to the side and mock whichever resident is intubating until some sort of catastrophe befalls us. So far, so good.

 

[deleted547339]

My usual intubating style is to stand off to the side and mock whichever resident is intubating until some sort of catastrophe befalls us. So far, so good.

I think you may be one of my attendings, lol.

 

[Xanthochromia]

I should have been more specific. The glidescope does fail, no doubt. The comment was more directed to "the emergency physician has a look of total panic on his face." I imagine that the look an EP would have would be no different than any other user of the glidescope, and probably would be more of "dammit" not a look of total panic.

 

[BLADEMDA]

I should have been more specific. The glidescope does fail, no doubt. The comment was more directed to "the emergency physician has a look of total panic on his face." I imagine that the look an EP would have would be no different than any other user of the glidescope, and probably would be more of "dammit" not a look of total panic.

Sir, I respectfully disagree. I work with ER Attendings who trained at several centers mentioned on this thread as top ER residencies. Yet, I am called to the ER frequently by them to intubate Grade 1 airways.

 

[Birdstrike]

Sir, I respectfully disagree. I work with ER Attendings who trained at several centers mentioned on this thread as top ER residencies. Yet, I am called to the ER frequently by them to intubate Grade 1 airways.

Wow. Sounds like you've got a problem there.

In about a decade in a busy community ED, I don't think I ever called anesthesia that had to save an airway for me. Maybe I did a few times and I just can't remember, but it was exceedingly rare if it happened, and I'm not someone who minds calling for help, and passing the baton. That's what you do so frequently in EM anyways. Okay, anesthesia is better at airway. Fine. Who cares? There tons of things EM does better than anesthesia, and that anesthesia doesn't even know how to do.

I've had a few really tough ones where I had a fellow EM attending take a look and we got the tube, and vice versa, a few that I put in for fellow EM attendings. One time I did call but by the time anesthesia arrived we had gotten the tube amongst the EM attendings with a glidescope. I've never had to cric anyone.

That being said, I worked at a place where Anesthesia wasn't always even in house at night and was busy enough during the day that there weren't necessarily going to arrive within seconds, even if called. For 3 am codes and intubations, I was Anesthesia. If anesthesia was in house for those airway emergencies, I never saw them after hours. Not even once.

So you may have a scenario where your intubaters are residents who aren't that experienced in airway yet, and the EM attendings aren't experienced because the inexperienced ones are doing all the tubes.

 

[BLADEMDA]

Wow. Sounds like you've got a problem there.

In about a decade in a busy community ED, I don't think I ever called anesthesia that had to save an airway for me. Maybe I did a few times and I just can't remember, but it was exceedingly rare if it happened, and I'm not someone who minds calling for help, and passing the baton. That's what you do so frequently in EM anyways. Okay, anesthesia is better at airway. Fine. Who cares? There tons of things EM does better than anesthesia, and that anesthesia doesn't even know how to do.

I've had a few really tough ones where I had a fellow EM attending take a look and we got the tube, and vice versa, a few that I put in for fellow EM attendings. One time I did call but by the time anesthesia arrived we had gotten the tube amongst the EM attendings with a glidescope. I've never had to cric anyone.

That being said, I worked at a place where Anesthesia wasn't always even in house at night and was busy enough during the day that there weren't necessarily going to arrive within seconds, even if called. For 3 am codes and intubations, I was Anesthesia. If anesthesia was in house for those airway emergencies, I never saw them after hours. Not even once.

So you may have a scenario where your intubaters are residents who aren't that experienced in airway yet, and the EM attendings aren't experienced because the inexperienced ones are doing all the tubes.

This isn't about who is better at intubations as much as comfort zone. We have 6 ER boarded physicians, 5 from the top programs mentioned frequently on this forum. All have less than 5 years of experience post residency and 3 have less than 2 years.

There are brand new glidescope and C Mac in the ER; plus, we have several more avail in the OR and ICU. So, the equipment isn't the issue. I believe some are just scared of the airway and the potential for a disaster.

I do agree with you that the ER Attendings need to step up to the plate more concerning routine intubations and not just call anesthesia for every trauma patient.

Any suggestions how I can get these Attendings to step up to the plate more concerning intubations in the ER?

 

[BLADEMDA]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

 

[WilcoWorld]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

I can't say what most attendings do/can do, but I can say that what you described is my expectation for my R2's and is covered in levels 2 and 3 (out of 5) of our airway management milestones - I expect my R3's to be even better than that. So, if "top program" graduates are not performing this way, either those programs aren't as good as they're reported to be, or (I would guess this is more likely) there is something about your hospital's system that is motivating the ED to act in this non-standard way. Could it be that the Dept. of Anesthesia overly-involves themselves in ED airway management?

 

[Rendar5]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

Yes. and I don't really have much glidescope access either =( I did call for anaesthesia once post-residency this past year, got the tube in by the time they arrived.

 

[Birdstrike]

This isn't about who is better at intubations as much as comfort zone. We have 6 ER boarded physicians, 5 from the top programs mentioned frequently on this forum. All have less than 5 years of experience post residency and 3 have less than 2 years...Any suggestions how I can get these Attendings to step up to the plate more concerning intubations in the ER?

One of two things is happening. Either these guys aren't confident in airway, they are calling you a ton because they're not confident and they're never going to get confident because you are so available. Trial by fire is the best way to learn and if they aren't forced to dig their way out of tough situations, they will never learn how to. More likely, something else is at work.

Smart and efficient Emergency Physicians follow the path of least resistance. They'll avoid the squeaky square wheel and ride one that's round and greased. Rather than incompetence, could the exact opposite be true? Are they calling you frequently simply because they can? Are you rolling up on the scene and the intubation is laughably easy, or do you walk away thinking, "Holy crap, that was harder than intubating a sleep deprived honey badger on steroids!"?

If they are calling you for easy intubations out of incompetence, you're screwed. For patient care, you need to show up and show up fast. You can't play politics with airway emergencies and maybe you do need to do some in house airway workshops so you aren't getting called constantly. I doubt this is the case if you have BC/BE EPs that trained at good places.

If they are calling all the time, because they know you preach "CALL ANESTHESIA EARLY", then they're going to take that all the way to the end zone. In that case they are not going to push the envelope. They're going to call you for every short-neck patient, every 300-pounder and everyone with a collar on their neck simply because they can. That's less work for them and frees them up to chew on the 20-patient-long tracking board of non-emergencies, which is really what admin wants them to do in the first place. If this is the case, you have to decide, do you want to be called early?

I never worked anywhere that Anesthesia gave pushback for not calling early enough, like you are preaching. In fact, it was the exact opposite. One time, I saw a partner call anesthesia, and when he came, the EM guy wanted to keep struggling with the tube. The anesthesiologist forceably grabbed the ETT and scope out of the EM guy's hand and a fight almost broke out in the trauma bay. It was completely ridiculous and inappropriate, but my point is that the environment was definitely not incentivized towards "calling early."

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

The vast majority of newly minted ER attendings should be intubating enough to be pretty confident with 99/100 intubations, and therefore should be more than comfortable being the only one one scene. However, if they work somewhere that they are pampered by an eager anesthesia service available within seconds to minutes with no pushback for routine intubations, then all bets are off.

 

[DrMom]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

I work nights in 3 community hospitals and am single coverage (only one in the entire hospital) for most of the hours of my shifts. I am comfortable, but understand that I could get into a situation where I really wish I had anesthesia for backup. We have a glidescope, bougies, LMAs all available along wth DL. Where I trained we never called anesthesia for an intubation once while I was there, so it really isn't something I'm in the pattern of thinking to do.

That said, one of the 3 hospitals has just started 24/7 anesthesia in house for OB. It is nice to know that I *could* call them if I felt the need. So far all I've called them for is a blood patch in a post LP HA.

 

[pinipig523]

thanks.
Just to clarify, are you going into the vallecula before sliding over midline?

Hmm... to clarify, I don't really move the blade midline but moreso I stay in my little corner to the right. Entering the mouth from the right allows you enough room to sweep the tongue to the left of the blade and allowing as little soft tissue wedged between the blade and the post pharynx/mandible.

Had another tube yesterday, edentulous woman... same technique, very easily viewable cords w/o issue. No need to crank or reposition. Just enter from the right corner, keep it in the right corner and external laryngeal manipulation and you're good (for the most part).

 

[bougiecric]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

What kind of hospital do you work in blade? I imagine there's variation, but at a large portion of community hospitals (including mine), ER docs do all emergent intubations in the hospital. Anesthesiologists aren't there past 5pm.

I've never seen an anesthesiologist in the ED to assist in an intubation. And they don't go to the daily floor/ICU codes to intubate -- just us ER docs. At my place, the anesthesiologist may intubate more frequently in general, but I intubate crashing patients infinitely more frequently. The anesthesiologists are happy to give up this role to us.

You may have a bit of selection bias, which I've also seen in other consultants. For every intubation you assist in, you aren't there for the 90 others that go smoothly. The urologist thinks we admit every kidney stone, the internist every chest pain, the ENT every PTA. The vast majority of events in the ED take place without your presence.

 

[Groove]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

Blade, I normally enjoy your contributions but I'm just calling complete horse **** on your post about being called down frequently for Grade 1 intubations in the ED. Something does NOT jive with your description, dude.

So... 6 EM boarded docs to staff the ED 24/7, huh? You either work in a small community hospital or you work in a hospital that has a VERY difficult time getting EM boarded docs and I'm assuming is staffing their ED with more than 6 providers.

Are you suuuure they are EM boarded and not FM or IM? Are you even more suuuure about where they trained? Most boarded docs aren't going to be paid enough or intellectually stimulated enough to work in a tiny community ED in the first place unless they're wanting to slow down and have intubated so many damn patients that they're happy to call anesthesia over and over again just to see how much they can make the monkey dance.

Is your department offering services in the ED for airway or are there some political variables at play that would influence how frequently you find yourself called down? Are you guys short on cases in this small hospital and need some extra billing to put peas and carrots on the plate? The anesthesiologists where I work would **** howitzers and fire them all off at once in the direction of hospital administration if they were expected to come down to the ED on a frequent basis.

I can't think of any ED environment in the last 6 yrs that I've been privy to watching the culture, habits, levels of training, etc.. where I could even hope to count past one hand where anesthesia has been called down. I realize I'm not as far out as others on this board but that's...including work, moonlighting, residency and even as a med student...like 6 or 7 EDs man. I saw it happen once during residency. I can't imagine any ED physician who's made it through virtually any ACGME EM residency program who would not feel comfortable intubating the vast majority of presenting airways in the ED.

 

[BLADEMDA]

Blade, I normally enjoy your contributions but I'm just calling complete horse **** on your post about being called down frequently for Grade 1 intubations in the ED. Something does NOT jive with your description, dude.

So... 6 EM boarded docs to staff the ED 24/7, huh? You either work in a small community hospital or you work in a hospital that has a VERY difficult time getting EM boarded docs and I'm assuming is staffing their ED with more than 6 providers.

Are you suuuure they are EM boarded and not FM or IM? Are you even more suuuure about where they trained? Most boarded docs aren't going to be paid enough or intellectually stimulated enough to work in a tiny community ED in the first place unless they're wanting to slow down and have intubated so many damn patients that they're happy to call anesthesia over and over again just to see how much they can make the monkey dance.

Is your department offering services in the ED for airway or are there some political variables at play that would influence how frequently you find yourself called down? Are you guys short on cases in this small hospital and need some extra billing to put peas and carrots on the plate? The anesthesiologists where I work would **** howitzers and fire them all off at once in the direction of hospital administration if they were expected to come down to the ED on a frequent basis.

I can't think of any ED environment in the last 6 yrs that I've been privy to watching the culture, habits, levels of training, etc.. where I could even hope to count past one hand where anesthesia has been called down. I realize I'm not as far out as others on this board but that's...including work, moonlighting, residency and even as a med student...like 6 or 7 EDs man. I saw it happen once during residency. I can't imagine any ED physician who's made it through virtually any ACGME EM residency program who would not feel comfortable intubating the vast majority of presenting airways in the ED.

Yes, there are many more non EP Physicians on staff in the emergency room. The ER department is trying to "convert" to a 60% model of ER boarded Physicians as there are 2 ER Doctors available per shift in the ER. This means that 1 Boarded ER Physician should be present per shift.

I'm sorry you would think that at this point in my career I would care about going to the ER for anything including intubations. The Institution had a long history of use IM/FP in the ER; so, for decades we intubated 100% of all patients in a timely manner (minutes). Slowly, the EP staff has become more involved in airway management and I am glad about that fact.

Previous posts have explained clearly to me that if an EP can turf the intubation to anesthesia many will do so. Since we are readily available (minutes from call to response) I suspect that is the situation. I plan on talking with the young, Superstar EP Physician in the next few days. I'll see what he has to say about the subject.

(FYI, I have personally shown FP ER attendings how to intubate using the Glidescope in the ER.)

 

[BLADEMDA]

Would any of you quit a job where the Hospital culture didn't let you intubate routinely in the ER; but instead, EPs called anesthesia to do them?