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Trauma Airway Intubation Is a Team Effort

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Field intubation of trauma patients should be a team effort.

Have a checklist for intubation of trauma patients, and assign your assisting colleagues a role to ensure success on the first attempt. Photo Courtesy Christopher T. Stephens, MD, MS, NREMPT-P


Greetings colleagues!

As the second part of this three-part series on the traumatic airway, we will now focus on intubating the trauma patient case that was introduced in the previous article, “Managing the Traumatic Airway.”

(Missed the first part of this three-part series? Click here to read Part I.)

Why is intubation of trauma patients being scrutinized across the nation, you ask? As an instructor of trauma airway management, I can assure you that it isn’t because you as field providers don’t know how to effectively intubate! In short, there are studies (whether sound or not) that are suggesting worse outcomes in patients who are intubated in the field.

So what, you ask? Sicker patients are sicker and need an endotracheal tube, right? Everyone agrees that there are some patients out there who just need to be intubated. Obstructed airways, vomit, blood and poor anatomy make traumatic airways challenging to manage in the field. In fact, these airways can be challenging in the trauma centers as well. Many patients simply can’t be oxygenated and ventilated effectively with a supraglottic airway—a or bag-valve mask (BVM) and oral airway for that matter, right? These are the cases that get our sympathetic nervous system going and put us in that position where “critical decision making” becomes extremely important.

The Intubation
So you have decided to intubate this trauma patient—who is 110 kg and looks like a small linebacker for your local professional football team. Here are some questions for you:

1. What help do you have?
2. What environment are you in (i.e., street, ditch or ambulance)?
3. Are you able to effectively oxygenate/ventilate this patient with basic tools as discussed previously?
4. Will you plan to do a blind nasal intubation or drug-facilitated oral intubation (rapid sequence intubation/RSI)?

These are some of the questions that must be thought about ahead of time, and a plan must have already been made so that the EMS team can be successful.

I like to teach EMTs and paramedics to think like pilots. Have a checklist and start at the top and work your way down. You will never miss anything this way. Assign your assisting colleagues a role to get the patient intubated successfully on the first attempt.

Ideally, you should have four EMS providers to intubate a trauma patient. The team leader is the one intubating. At this point, the team leader should be assisting the patient’s airway and pre-oxygenating with 100% oxygen via a BVM. Pre-oxygenation is VERY important. It will buy you more time to get that tube in the right hole. You should do this for blind nasal intubations as well. Trauma patients tend to desaturate at an alarming rate because most have been hypoventilating to this point due to pain, semiconsciousness, pneumo- or hemothoraces, etc. And remember, all trauma patients are full stomachs. Some have already aspirated prior to your arrival, which also works against you. All of these conditions make your intubation attempts less forgiving, and you must be prepared to act quickly if the patient becomes challenging and/or desaturates.

Once you have pre-oxygenated your patient for at least 60 seconds, attempt your intubation. If it’s a blind nasal intubation, you may have more time because the patient is still breathing. You also have the luxury to just assist them to the hospital if it fails. If you’re planning a drug-facilitated intubation, then all bets are off. Once you have decided to push drugs, you had better have your skills, colleagues and equipment ready for action.

During pre-oxygenation of the patient, the team leader must assign roles. The second medic will draw up and be responsible for pushing drugs, then handing supplies to the intubating team leader (i.e., endotracheal tube, suction, bougie, another blade, video laryngoscope, etc).

The third provider is responsible for removing the front of the cervical collar (yes, the front of the c-collar MUST be removed PRIOR to laryngoscopy) and holding cricoid pressure correctly. Note: Cricoid pressure needs to be learned correctly and practiced. Some protocols have done away with cricoid pressure; I feel that it’s still an important tool to be used in traumatic airways with full stomachs.

The fourth provider will hold in-line manual stabilization of the cervical spine throughout the intubation. When the team leader states that they’re ready, the second medic should push the appropriate drugs and appropriate doses. This is a decision that has to be made correctly and using expert paramedic critical decision techniques. Understanding the physiology/pharmacology of rapid sequence intubation (RSI) is as important as the skill itself. How sick is the patient? What are their vital signs prior to pushing drugs? Do they have pulses (central or peripheral?) Are they in shock? Do they have signs of a head injury?

Which of roles below do you most often play during the field intubation of a trauma patient?

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These are questions that must be answered during a rapid primary and secondary survey while preparing to intubate the patient. Is the patient combative due to shock, head injury, alcohol/drugs, or all of the above? If able, try and get a baseline set of vital signs prior to pushing drugs. This will help guide your drug choice and dosing. Drug selection and dosing is an EXTREMELY important topic for trauma patients and should be discussed at length with your medical director and training supervisors. Anesthetic agents are powerful and can make patients worse if used incorrectly.

There are many issues to think about when dealing with a traumatic airway, and hopefully you will have some time to work through a good plan of action so if things start to go wrong, your checklist and plan will be there for you to fall back on.

Once the patient has been relaxed with succinylcholine or an alternative paralytic agent, the team leader should perform their laryngoscopy with the blade they’re most comfortable using. Remember, your first shot is always your best shot! I teach trauma airways with a Macintosh 3 blade for most adults because I find it easier for medics and trainees to keep the tongue out of the way with the wider Macintosh blade.

As an alternative, you may also use a video laryngoscope, such as the Glidescope Ranger, for your intubation. The Glidescope Ranger has been useful for managing traumatic airways. It allows everyone assisting to see what the team leader is seeing, which can therefore help them anticipate what the team leader may need to get the job done, such as suction, bougie or a smaller endotracheal tube. As with any piece of airway equipment, there’s a learning curve with video laryngoscopy. You must practice it on mannequins, cadavers in airway labs and on live patients in the operating room, if possible.

I want to say a few words about the intubating stylet or bougie. Since I manage traumatic airways for a living, in my opinion, the bougie is the single most important piece of intubating equipment. This little flexible styllete has been my savior during many a difficult airway in the trauma center. That being said, a bougie and video laryngoscope is a VERY effective combination of equipment to intubate the trauma patient. I encourage each of you to grab an airway mannequin, a bougie and a demo Glidescope Ranger and practice this technique. This is going to be the wave of the future for airway management, especially in the uncontrolled field environment, where help can be lacking.

If you can’t see a view of the vocal cords or confirm the tube to be in the esophagus, you must go to Plan B. This may include changing blades, switching to a video laryngoscope, or perhaps allowing another, more-experienced airway operator to assist. Do NOT forget to attempt oxygenating and ventilating the patient with an oral/nasal airway and BVM between intubation attempts. Do your best to get the patient as close to 100% oxygen saturation as possible prior to your next intubation attempt.

If the second attempt fails, consider either placing a supraglottic airway device or simply performing BVM assisted ventilations with an oral/nasal airway throughout transport. Remember, this technique sometimes requires two rescuers to perform adequately. If you can’t intubate and can’t ventilate the patient, you must proceed to a surgical airway—either a needle or open surgical cricothyroidotomy. We will discuss this in the next article.

The Confirmation
Once the endotracheal tube is placed, it’s important for tube confirmation to be established. This can be done in many ways. Chest rise and bilateral breath sounds are important but can sometimes be misleading. If the patient is warm and still perfusing, tube fogging should be noted, as well as end-tidal carbon dioxide (ETCO2). Either an easy cap (calorimetric) ETCO2 or continuous waveform capnography should be employed as the gold standard for tube confirmation. Continuous waveform capnography ideally should be used by every medic unit that’s intubating patients in the field. This will be discussed further in the next article.

Once the correct tube location is confirmed, be certain that the tube is secured well, the cervical collar is replaced, and the tube location is reassessed after securing because tubes sometimes migrate into the right mainstem bronchus when being secured. At this point, you’re still not out of the woods! Now that you have successfully intubated the patient, you must worry about their physiology while transporting. This is a point that many field providers dismiss when managing airways in the field and a topic that may prevent medical directors from removing intubation from protocols around the nation. So there you have it—four providers ideally to get the task done correctly!

Stay tuned for the final article in this series of managing the traumatic airway.

Do you have access to a video laryngoscope?

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Christopher T. Stephens, MD, MS, NREMT-P

Completed BS in Biology from Loyola Marymount University. Completed paramedic school at Houston Community College and trained with the Houston Fire Department. Paramedic in Houston, Texas and Galveston, Texas. University of Houston College of Pharmacy (MS in Pharmacology), University of Texas Medical Branch School of Medicine – (MD, Anesthesiology Residency) Trauma Anesthesiology Fellowship – University of Maryland Shock Trauma Center Currently Assistant Professor of Anesthesiology at University of Maryland School of Medicine and Attending Trauma Anesthesiologist - R Adams Cowley Shock Trauma Center, Baltimore, MD. Director of Education, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Medical Director, Maryland Fire&Rescue Institute. Instructor for Maryland State Police Aviation Command; Flight Physician, Tactical Physician

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Video Laryngoscopy’s Place in an Ambulance

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Paramedics might have to adapt what they hear during formal intubation training. (Photo JEMS)

By A.J. Heightman, MPA, EMT-P

I remember gowning up early in the morning and meeting with the assigned anesthesiologist to go over the OR schedule and being told whom I could and couldn’t intubate. If the patient had a jutting jaw, a large neck, a history of cervical fracture or poor teeth, I wasn’t allowed to intubate them and was required to just watch the anesthesiologist manage these “difficult” patients.

The funny thing is that many of the patients I was later called on to intubate in the street met one or more of those exclusionary criteria.

Over time, anesthesiologists have become less willing to expose themselves to liability by allowing paramedic students to intubate patients they were contracted to manage. Therefore, many of today’s paramedics never intubated a live patient prior to being turned loose to intubate in the prehospital arena. That’s a frightening thought.

Laryngoscopy, as we’ve traditionally known it, is also being re-evaluated and reprioritized in protocols by EMS medical directors. The change comes in light of studies showing that all paramedics are not equally proficient at the skill, and because the emphasis in cardiac arrest resuscitation is now more directed at continuous and consistent compressions in the early stages of resuscitation than airway management by intubation.

The increasing number of paramedics deployed on fire apparatus and ambulances is also resulting in fewer opportunities in many EMS systems to place endotracheal tubes, with some placing only one or two tubes annually. This is presenting new challenges to medical directors and service training staff because they must more frequently review and refresh paramedics on this critical skill. This also increases service and municipality exposure to liability for misplaced endo­tracheal tubes by their paramedics.

Further, the current demand on hospitals to report and reduce medical errors has a significant ripple effect on prehospital providers transporting intubated patients to emergency departments (EDs), with more hospital scrutiny of prehospital airway care than ever before.

What this all means is that fewer ET tubes will be placed in many EMS systems, those that are placed will have to be accomplished with little or no interruption in compressions, and each tube will be carefully evaluated on arrival at an ED.

Placing an ET tube with standard eye-to-vocal cord visualization during compressions, in a moving ambulance, and in the tight confines and configurations presented in helicopters, is a difficult task that’s prompting hospitals, ground EMS systems and aeromedical programs to consider video laryngoscopy.

What started out as a creative training aid by innovators like Richard Levitan, MD, allowing students to observe the anatomy of patients and the process of intubation through video imaging, has evolved. It’s now refined and incorporated into compact video laryngoscopes, such as the Verathon® GlideScope® Ranger, which shows you an image on its screen that’s twice the actual anatomical size.

The clarity and utility of the video laryngoscope are so good that anesthesiologists, ED physicians and flight crews are using them on a regular basis. This trend has direct ramifications on the prehospital performance of intubation because, as in-hospital airway management processes and equipment changes, so too will prehospital processes and equipment.

The supplement to JEMS “The Perfect View” presents the advent of the device and how EMS systems are using the tool so you can understand the technology and its potential impact on you and your service in the future.

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Roadmap to the Glottis

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When we intubate a patient, all we really want to do is place the endotracheal tube in the glottis. Let’s face it, the glottic opening can be a tough feature to locate on a good day, let alone wh

To get two the epiglottis and the posterior cartilages, your two new best intubation buddies, you have to get past the tongue first. Illustration JEMS/Wainwright Media

en things just aren’t going well. Blood, vomit, laryngospasms, edema; you know the drill. If you want to find the glottis, stop looking for the glottis. What? Read on, friends, I’ll show you.

Anatomy of the Larynx
The larynx is made up of three single cartilages and three pairs of cartilages.

The thyroid is the largest of the laryngeal cartilages. It’s within this cartilage that the glottis is located. The anterior ends of the vocal cords are attached to the thyroid cartilage. This feature gives us the ability to directly move the glottis to improve our view. Known by different names, external laryngeal manipulation (ELM), backward upward rightward pressure (BURP), digital physical laryngeal manipulation; the procedure of manipulating the thyroid cartilage to optimize the glottic view has been described for many years.(1–3)

The cricoid cartilage, the most inferior of the laryngeal cartilages, is the only laryngeal cartilage that’s a complete ring. In pediatric airway, the cricoid cartilage is the narrowest part of the airway. Non-cuffed tubes fit snuggly into the ring to prevent air leak. Cricoid pressure has been used to improve glottic view during laryngoscopy, but I think you will find that laryngeal manipulation does a better job of optimizing the glottic view. One of the very best studies I’ve read on the use of cricoid pressure was published in 2007. The authors concluded, “We recommend that the removal of cricoid pressure be an immediate consideration if there is any difficulty either intubating or ventilating the ED patient.”(4) As an airway professional, you owe it to yourself to read the entire study.

Let me now introduce to you, straight from the back of the tongue—the most important airway landmark, the intubator’s very best airway friend, the gateway to the glottis—THE EPIGLOTTIS!

Remember when I told you to stop looking for the glottis? I want you to start looking for the epiglottis. Remember from our last lesson that the inferior (extrinsic) tongue muscles are connected to the mandible, hyoid and epiglottis. We can use that connection to locate the epiglottis. I’ve found the epiglottis to be easier to locate on a more reliable basis for both novice and experienced providers. Sounds like a study in the making.

Try this: Insert the laryngoscope blade into the patient’s mouth and just follow the tongue posteriorly until you locate the epiglottis. Lift the epiglottis and there’s the glottic opening. Most of the time, it’s just that easy.

Posterior Cartilages
The second best friend of the intubator is the group of three pairs of cartilages, which lie along the posterior border of the glottic opening; the corniculate, cunneiform and aryetnoid cartilages. The arytenoids sit on top of the posterior portion of the cricoid cartilage. The posterior end of each vocal cord is attached to an arytenoid cartilage. The length and medial-lateral positioning of the vocal cords are accomplished by movements of the arytenoids. The arytenoids can’t be seen in the standard laryngospic view because they’re buried in tissue.

The corniculates sit on top of the arytenoids and are seen during laryngoscopy immediately lateral to the interarytenoid notch. The cureiform are embedded in the aryepiglottic folds. They give support to these membranes, which connect the arytenoids to the epiglottis. In the standard laryngoscopic view, the cuneiform can be seen immediately lateral to each of the corniculates.

Collectively these cartilages go by a variety of names: the arytenoids, posterior cartilages, nodes. Regardless of which term you use, know that they are the posterior border of the opening to the glottis and are identified by a notch in the middle and two pairs of bumps on either side.

Conclusion
So there you are. Your new best intubation buddy is the epiglottis, and your second best buddy, the posterior cartilages. I find it ironic that these most helpful features lay right behind our nemesis, the tongue. A good knowledge of the airway anatomy is really a roadmap to success. Bust open that A&P book that you’ve got shoved up there on the shelf. It will make you a better provider.

Take care and be safe.
Charlie

References
1. Benumof JL & Cooper SD. Qualitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anesth. 1996;8(2):136–140.
2. Knill RL. Difficult laryngoscopy made easy with a “BURP.” Can J Anaesth.1993;40(3):279–282.
3. Levitan RM, Mickler & Hollander JE. Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002;40(1):30–37.
4. Ellis DY, Harris T & Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann of Emer Med. 2007;50(6): 653–665

Watch a video of Charlie explaining how to visualize the glottis.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Five Anatomical Features that Affect Ventilation

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Understanding respiratory and airway anatomy can help EMS providers properly ventilate a patient using basic skills. (Illustration JEMS)

I have a huge interest in anatomical studies. Besides finding anatomy just plain interesting, I think a thorough knowledge of the human body helps us do a better job taking care of our patients.

Bag-valve mask ventilation is a real cornerstone of airway management. You have to accomplish it successfully, and you can’t move on to advanced techniques without it.

When encountering difficulty in mask ventilating a patient, it’s usually because of one of the three following problems:

  • A poor mask seal;
  • An obstruction somewhere in the airway; and
  • Increased intra-thoracic pressure.

In one study of more than 1,500 patients, five criteria were recognized as independent factors for difficult mask ventilation: age older than 55 years, body mass index (BMI) of more than 26 kg/m2, presence of a beard, lack of teeth and history of snoring. (1) You should be able to determine the existence of these criteria fairly quickly just by looking at your patient and speaking with their family.

I’ve put together my own list of the top five anatomical features I feel affect our ability to provide quality mask ventilation to our patients. Stop right now and write down the five parts of the airway anatomy you think have the greatest impact; compare your list to mine when you finish the article.

Number 5: The Abdomen
I’d like a nice flat tummy. Hey, who wouldn’t? But the Centers for Disease Control says we’re all getting bigger. They determined the average adult male has a BMI of 26.6 and an adult female a BMI of 26.5. (2) In general, the larger the abdomen, the more difficult it is to ventilate a patient.

As the diaphragm contracts, it moves inferiorly into the abdomen. This movement generates negative pressure in the thoracic cavity and air rushes into the lungs. To exhale, the diaphragm relaxes and returns to its normal position. Air pressure in the thoracic cavity increases and air leaves the lungs. That’s how it’s supposed to work. Add some weight to the abdomen and the diaphragm doesn’t work so well.

Try this: Lay supine on the floor and determine your ease of breathing. Have a trusted friend place a five-pound bag of sugar on your belly. What’s your ease of breathing now? Keep adding bags of sugar until you really have to work just to draw a breath. This is exactly how an obese patient feels when we place them supine.

In a patient with a large abdomen, the additional weight on the abdomen raises intra-abdominal pressure, which pushes the diaphragm superiorly into the chest. This movement reduces space in the thoracic cavity, reduces tidal volume and raises intra thoracic pressure. When the diaphragm contracts, it not only has to move the normal abdominal contents, but it also has to generate enough intra-abdominal pressure to raise the weight of additional tissue sitting on the abdomen. This is why these patients report increased dyspnea when placed supine and why we have a more difficult time ventilating them.

Number 4: The Neck
I have two questions about the neck: How clearly visible are the anterior landmarks? How mobile is the neck?

You should be able to visualize, or at least very easily palpate, the thyroid cartilage and the cricoid cartilage. At times, there can be so much tissue covering these features that it appears the patient doesn’t even have a neck. If you can’t locate these features, it will be difficult to manipulate them to optimize the airway.

The thyroid cartilage is the largest of the laryngeal cartilages. It’s within this structure that the vocal cords and glottic opening lie. External manipulation of the thyroid cartilage can enhance glottic alignment with the upper airway. (3)

The cricoid cartilage is immediately inferior to the thyroid cartilage and anterior to the esophagus. For years, providers applied cricoid pressure in an attempt to improve glottic view during laryngoscopy and to reduce the introduction of air into the stomach during assisted ventilation. Although the 2010 American Heart Association guidelines don’t recommend routine use of cricoid pressure, some major medical institutions and EMS programs continue to find it useful in their programs.

To locate these structures, start with your finger at the sternal notch. Move your finger upward with gentle pressure on the anterior neck. The first hard ring you palpate is the cricoid cartilage. Continue to move your finger slightly upward, and you’ll feel a small depression immediately superior to the cricoid cartilage; this depression is the crico-thyroid membrane. Move your finger further upward, and you’ll feel a large, prominent structure, which is the thyroid cartilage.

Neck mobility directly affects our ability to position the airway. Placing a patient in the sniffing position improves glottic alignment with the pharyngeal area. (4) A good field landmark to obtain the correct position is to elevate the head so the ear canal is even or above the level of the sternum. The more easily you can manipulate the patient’s neck, the easier it is to align the three airway axes and find the right position to maximize air flow.

Number 3: The Teeth
Strictly from an airway management point of view, teeth really just get in the way when you’re trying to obtain a glottic view or attempting to place an adjunct in the patient’s mouth. Try to mask ventilate someone who’s missing teeth, and that’s a completely different story.

A good set of teeth gives form to the face and allows for a good mask seal. No teeth will give you just the opposite. I’ve heard stories of packing the cheeks with gauze to improve the fit—even tried it myself once. But friends, nothing beats a Grade A set of original issue teeth to provide a good mask seal and a stable platform from which to ventilate.

The down side to a full set of teeth is that they take up space in the mouth and reduce mouth opening distance as compared to our edentulous patients. It may be difficult to insert airway adjuncts into the patient’s mouth when the distance between the upper and lower incisors is less than 6 cm (about three fingers).

Number 2: The Mandible
When shopping for a mandible, you want two features: mobility and alignment.

Remember the last time you cared for a patient with a clenched jaw? You can’t open the mouth. You can’t insert an oropharyngeal airway (OPA) device. You can’t insert a suction tip. The ability to open the mouth wide certainly makes it easier to mask ventilate or insert airway adjuncts. The simple capacity to displace the mandible anteriorly and pull the tongue off the back of the throat can make all the difference in moving air. We can induce poor mobility by simply applying a cervical collar or applying posterior pressure on the mandible while trying to get a good mask seal. As with the neck, your ability to move a patient’s mandible can really enhance your ability to ventilate them.

The optimal alignment of the mandible is directly below the maxilla so there’s a smooth transition from the nose to the chin. An uneven surface reduces your ability to obtain a good mask seal. A significantly receding mandible may not allow you to fully displace the tongue off of the throat with a chin life or jaw thrust.

 

Number 1: The Tongue
When I look at a sagittal view of the upper airway, the first feature that always draws my attention is the tongue. Look at the size of it. The tongue takes up about 85–90% of the oral cavity. (5) It’s the largest structure in the mouth, highly vascular and just waiting to obstruct the airway. The tongue presents us with challenges to basic and advance airway techniques.

The superior (intrinsic) muscles don’t attach to any structures outside the tongue, which is great when you need your tongue to change shape to form words. In the less-than-conscious individual, this is the portion of the tongue that relaxes, moves posteriorly and obstructs the airway. You drift off to sleep, your tongue relaxes, and the snoring starts. You get an elbow to the ribs, you roll over, your tongue flops forward and the snoring stops. This is why we place patients in the lateral recovery position. Correct placement of an OPA device holds the superior muscles of the tongue off of the back of the throat to create an open air passage.

The inferior (extrinsic) tongue muscles connect to such external structures as the mandible, hyoid and epiglottis. It’s these connections that are critical to opening a patient’s airway. When using a chin lift technique, the mandible moves anterior along with the attached inferior tongue muscles. Since the inferior muscles are connected to the superior, airway obstructing muscles, the tongue is lifted off of the back of the throat and opens the airway. Since the epiglottis is also attached to the inferior muscle group, it lifts upward as the mandible moves anteriorly. This is an added airway bonus.

There you have it folks, my top five anatomical features that impact our ability to mask ventilate a patient. How did my list compare to yours?

In an upcoming article, we’ll build on this lesson and look at features of the airway anatomy that impact our ability to provide advance airway management.

For now, put this information to work for you: Specifically, look at these airway structures on all your patients and note their variations. Consider the ease with which you could mask ventilate each patient and what you could do to optimize it.

I’ll leave you with a quote from a good paramedic and a great friend.

“The consistent delivery of basic airway skills is usually more helpful than an occasional act of brilliance,” —Robin B. Davis, NREMT-P

Charlie


References

  1. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92(5):1229–1236.
  2. Center for Disease Control. National health and nutrition examination survey. Centers for Disease Control and Prevention, National Center for Health Statistics. 2003; Publication no. 03-0260.
  3. Levitan RM, Mickler T & Hollander JE. Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002; 40(1):30–37.
  4. Levitan RM, Mechem CC, Ochroch EA, et al. Head-elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003; 41(3):322–330.
  5. Iida-Kondo C, Yoshino N, Kurabayashi T, et al. Comparison of tongue volume/oral cavity volume ration between obstructive sleep apnea syndrome patients and normal adults using magnetic resonance imaging. J Med Dent Sci. 2006; 53(2):119–126.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Should EMS Intubate?

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The Intubation Debate

Intubation is one of many tools in the EMS provider’s airway management toolbox. (Photo A.J. Heightman)

Did you make it to the 2011 EMS Today Conference & Exposition? What a great experience! I had the honor to moderate a panel discussion titled “Should We Intubate?” Four great panelists and about 200 folks in the audience resulted in lively debates and a challenge to be great EMS providers. As the moderator, I really didn’t get the chance to stand on my soapbox, so I’ll take that opportunity now.

Why does the thought of taking endotracheal intubation out of the hands of paramedics invoke such a visceral response? I didn’t whine when the EOA left. No heartburn when I put MAST back on the shelf. What is it about an ET tube? Because for decades, it’s all we had.

Endotracheal intubation via direct laryngoscopy has been used since the late 1800s.1 Numerous BLS airways were developed during World War II. Extraglottic airways appeared in our airway kits in the early 1980s.2 Flexible and rigid fiber optic laryngoscopes made their way into operating rooms in the early 1990s. It wasn’t until the turn of the century that laryngoscopy changed for EMS with the development of video laryngoscopes.

For about 110 years, direct laryngoscopy has been THE method to place an endotracheal tube. In EMS, we’ve relied on this method for about 40 years (depending on how you write the timeline). We reinforce the dogma that the endotracheal tube is the airway of choice by referring to all other devices as “rescue airways.”

Should we intubate?

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So I ask the question: Should we intubate? When it’s appropriate, absolutely. The endotracheal tube is a wonderful tool that has been successfully placed and managed for decades outside of the operating room. It continues to be used successfully by EMS professionals on a daily basis.

I’ve read a ream of studies professing the evils of prehospital endotracheal intubation. While there are descriptions of hypoxemia and trauma during endotracheal tube placement, the vast majority of the described evils come from what is done after the tube is placed; hyperventilation, hypocarbia, unrecognized misplaced tubes and reduction of blood return to central circulation.

Wait a minute; can’t those same evils occur with extraglottic airway devices or even a bag-valve mask? Why yes, they can. You can also add gastric distention, vomiting and reduced tidal volume to the BVM list. We have to do a great job managing any airway device.

As technology has progressed, we’ve been given fantastic new tools to help us do a better job. We’ve all seen studies that show the effectiveness of end-tidal carbon dioxide monitoring to verify tube placement and appropriately ventilate. Since 2003, studies from hospital and EMS settings have published results of the use of video laryngoscopy; shorter intubation times than direct laryngoscopy, high first pass success rates, and Grade I–II views with poor neck mobility.3-5 The gum elastic bougie, (and its plastic alternatives) is such a simple and incredibly effective tool, it should be mandatory in every airway kit. I’m quite sure you can list several other items. Proven technology must be embraced as the standard of care for our patients.

Are you allowed to intubate?

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So, I ask: Should you intubate? It’s entirely up to you. Are you willing to use the tool that best fits the patient, the conditions and your abilities? Are you willing to do what it takes to be a professional airway manager?

I’ll leave you with the challenge leveled at the end of the panel discussion. All of us must drive to excel as medical professionals, to refuse to accept mediocrity as a level of care and to simply do the very best for our patients.

I’m excited and humbled at the opportunity to provide information that will help all of us become better airway managers. I look forward to hearing from you.

Until next time, take care and be safe.

Charlie


References

  1. Bailey B (1996). “Laryngoscopy and laryngoscopes–who’s first?: The forefathers/four fathers of laryngology.” The Laryngoscope. 106(8):939–943, 1996.
  2. Donmichael TA. US Patent 4497318, Feb. 5, 1985.
  3. Agro F, Barzoi G, Montecchia F. “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” Br J Anaesth. 90(5):705–706, 2003.
  4. Nouruzi-Sedeh P, Schumann M, Groeben H. “Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.” Anesthesiology. 110(1):32–37, 2009.
  5. Cormack RS & Lehane J. “Difficult tracheal intubation in obstetrics.” Anaesthesia 39(11):1105–1111, 1984.

Glossary

EOA = Esophageal obturator airway

MAST = medical anti-shock trousers

BVM = bag-valve mask

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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    Featured Airway Products

    Providing emergency patient care on the ground or in the air is complex and challenging. That's why the tools used by paramedics and EMTs must be adaptable in a constantly changing clinical situation — quickly operational, rugged and easy to use. Learn more about EMS airway management.

    GlideScope Ranger

    The GlideScope Ranger video laryngoscope delivers consistently clear airway views enabling faster intubations in EMS settings. Available in reusable or single-use configurations.

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    GlideScope Cobalt AVL

    GlideScope Cobalt AVL

    The GlideScope Cobalt AVL video laryngoscope offers airway views in DVD-clarity, along with real-time recording. On its own or when combined with the GlideScope Direct intubation trainer, the Cobalt AVL is an ideal tool to facilitate instruction of laryngoscopy.

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    GlideScope AVL Reusable

    GlideScope Cobalt AVL

    The GlideScope AVL Reusable video laryngoscope offers airway views in DVD-clarity, along with real-time recording. On its own or when combined with the GlideScope Direct intubation trainer, the AVL is an ideal tool to facilitate instruction of laryngoscopy.

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