Tag Archive | "paramedic intubation"

Scary Airways

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Overcoming fear is the first step to slaying the dragon of a difficult airway. The next is choosing your tools to face the monster. Photo Chris Swabb

By Jim Radcliffe, BS, MBA, EMT-P

I hope everyone is having a great year. I know the economy is tight and there’s all this political stuff going on in and out of our industry, but that’s not why we got into this business in the first place. Somewhere in our lives, we were bitten by the EMS bug. Some of us really came down with it and we have spent most of our lives serving other people. Believe it or not, I’ve had the honor and privilege of knowing some paramedics and EMT’s in their 80s still serving and teaching, running circles around their younger counterparts.

However, it doesn’t matter how old or young, new to medicine or experienced you are, we all have to understand the anatomy and physiology (A&P). Few have the luxury of going through programs with excellent science programs that mirror what medical school students must learn, so A&P becomes scary. One particularly scary and disorienting area of A&P is the airway. The A&P of the airway is scary for a couple reasons, I know it was to me and still is today—but for different reasons. I would like us to take a few minutes to take a look at the A&P from a couple perspectives and talk about how we might make it a little less scary for everyone.

Bring on the Nightmares
Do you remember when you were a student or a new paramedic and going into the operating room for an airway rotation? How about that first field intubation you did? It was probably in front of your preceptor or field training officer (FTO). Wow, I know it was a couple decades ago for me, but I still remember that my hands were shaking and I was sweating while trying to verbally walk myself through the steps and reviewing the A&P in my head.

I did all this as I attempted to impress the anesthesiologist behind me, whom I had met only an hour before. Then I remember noticing that he was right behind me, and his chin was almost on my shoulder as he was trying to look down my laryngoscope blade to see what I was seeing. I know it sounds like a Steve Berry cartoon, but it’s true. It took me several years and my turn as a preceptor and instructor to understand that intubation is not just scary for the student but also for the preceptors and FTOs.

Over the past several years I’ve learned a couple things I think could really help us conquer this fear of the airway A&P and help us all to be better providers and paramedics. So the first thing we have to do is what my good friend Charlie used to say, “Take a deep breath and relax and think about what’s for lunch.” To be a good provider, you have to know the A&P upside down and backwards (and I like to say so well that you have nightmares about the epiglottis.)

Monsters, Dragons & Beasts—Oh My!
So let’s start at the top and review some basic A&P that we all must know. Air comes into our patient through the nose and the mouth as they breathe or we breathe for them. The air going in through the nose is warm filtered and humidified as it goes over the turbinates lined with cilia to filter out the dust and things floating in the air to keep it out of our airways. That air then proceeds down through the nasal pharynx, connects with the posterior oral airway and goes down to the larynx.

Remember that the oral and nasal passages are separated by the hard and soft pallet. The air going in through the mouth must pass by the teeth and proceed the first monster of the airway, the tongue. Yes it seems like and looks like a monster the first time you attempt to slay the dragon of an airway and you are staring down a laryngoscope blade at that beast. No wonder it’s the largest and most common airway obstruction. After getting passed the tongue there is this strange character that you meet called the uvala. He is just hanging there off of the soft pallet pointing you south toward the darkness of the airway. When the patient is breathing this is like a wind tunnel but when you are marching through here with a little metal stick with a light on the end of it the air is still, stagnate and full of foul odors. As you begin to round the corner to head down to the larynx the uvula reminds you, “watch out for the epiglottis just around the corner.

Oh yes the epiglottis, not quite as large as the tongue but still a monster that’s slippery and illusive. For years, I would intubate by looking for the vocal cords Then one day, I realized that everyone has an epiglottis and it’s always in the same place. Think about it for a minute; pull up that old A&P picture from the recesses of your brain and look at the side view. Yep that’s it. Follow the center of the tongue, the forough, to the base of the tongue. At the base of every tongue is an epiglottis. The landmark between the tongue and the epiglottis is called the vallecula. The epiglottis comes in many sizes depending on the size of the patient and how many Whoppers they consume daily.

Which landmark do you look for most when beginning an intubation?

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If you’re intubating, then you most likely have laid the patient flat on their back. (I’m not sure who ever thought to do that, because all the stomach content is now running toward the posterior oral airway and we have to lift all of the structures out of the way.) If you can, place the patient in a low Fowler’s position, it will make your life so much easier and help fix that crook in your neck as well.

Weapons of Choice
If your patient is large, you’ll most likely find a large, floppy epiglottis lying in a pool of slime at the bottom of the posterior oral airway, just waiting to jump up and ruin your day. You’ll need one other weapon in your arsenal to slay this monster, which would be your suction, never leave home without it. It seems that this monster is a lot easier to defeat when you take away his hiding places. Also when you put the patient in a low fowler’s position and put about two inches of padding behind the patient’s head you straighten out the airway and take away the corner’s for the epiglottis to hide. Choosing the correct light stick (laryngyscope blade) is important here, depending on the size of this epiglottis you may need a thin, wide or curved stick to defeat the monster. We will save the choice of weapon for another discussion. Once you defeat these two monsters, entering the cave of the airway dragon is pretty easy from there.

Over the past several years, numerous additions to the EMS airway resources have improved prehospital airway management. One simple change has been the introduction of fiberoptic and LED lighting systems on laryngoscope blades, which has made illuminating the airway much easier.

The introduction of video laryngoscope, which enables users to capitalize on a superior glottic view and access provided by the video image, has significantly changed first attempt success rates When you’re dealing with difficult airways in which you can’t get good line-of-sight visualization, video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. It has also given us a huge educational advantage. In teaching settings, the video laryngoscope allows the preceptor or instructor to see what the student or new provider is observing. For the classroom or lab setting, video trainers allow the instructor to walk the student through the airway and discuss issues that are encountered. I have found the use of video laryngoscope in cadaver labs has been extremely helpful to the students. Many video laryngoscopes have a “video out” feature that allows you to push the image to a larger screen for a group to be able to see what the intubator—whether the instructor or another student—is observing.

No More Fear
Over the years teaching in cadaver and airway classes, students will ask why they were never told these things in their initial training. I have found that understanding the A&P, the use of landmarks and the introduction of video laryngoscope has helped to take the scariness out of prehospital airway management. Hope this helps your practice.

Be Safe,
Jim Radcliffe, MBA, BS, EMT-P

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Airway Finesse

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Visualizing the Airway

Video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. Photo James Radcliffe

The ancient Egyptians figured this out when they built the Great Pyramids thousands of years ago. They used tools to work smarter, not harder.

Intubation is the same way; for years I’ve been watching students and experienced providers in labs and in the field do the same exact thing as the guy moving the furniture. The more frustrated they get, the more brute force they apply and the worse the situation gets. It isn’t until they slow down and begin to work smarter that they begin to have success. There are numerous ways that prehospital providers can gain mechanical advantage and optimize our laryngeal view. We have to understand which tools to use for this each patient during each intubation attempt. Choosing the right blade or techniques is important, as is understanding that some patients or situations dictate other options, such as blind-insertion airways or video laryngoscopy. Video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation when you’re dealing with difficult airways in which you can’t get good line-of-sight visualization.

People have been placing metal sticks in mouths for centuries to examine the oral pharynx, and inventors have been keeping pace by creating a bigger and better device at every turn. But let’s stop and consider what we are really trying to accomplish with direct laryngoscopy.

Four Steps for Direct Laryngoscopy
Step one is to move any obstacles, such as vomit, food or teeth, out of the field of view with good suction. Trying to visualize an airway through all that stuff is like trying to drive 60 mph in a torrential rain storm without windshield wipers. You’re not going to be able to drive in the rain without wipers, and you’re not going to successfully intubate without suction. The suction unit is our best friend when it comes to airway management for EMS (but it seems to be the one piece of equipment that is left in the truck, missing a hose or uncharged, so it often isn’t there when the need arises).Once we clear the airway, then we’re ready to take a look at the airway.

Step two is to get that first look before anything else gets in the airway. The scissor technique allows us to open the mouth of the supine patient so we can get a great look at the posterior oral pharynx. This is where we begin to identify our landmarks and possible obstructions. Looking straight into the mouth, the first thing we see is the tongue. The size of the tongue plays a part in determining which blade we will use for intubation. If we’re able to see past the tongue, we’ll see the uvula lying in the posterior oral pharynx. As we begin looking into the mouth, we consider the proportion of the structures to the overall space. This helps determine the level of difficulty—or as a good friend always says, “how fun” it will be manage the airway. Once we have a good assessment, we’ll have some idea what tools we might want to use.

Which level of difficulty during intubation do you prefer?

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Step three is to choose the right tool for the job. Prior even to opening the airway, the experienced provider has already assessed the patient externally to determine the level of difficulty to anticipate and the equipment to use. Several scoring systems out there assess the level of difficulty of an airway. The most common is the Mallampati score, which ranges from 1 to 4 with 1 being the best view and 4 being the worst. Richard Levitan, MD, came up with a great tool that we will refer to as the “Four Ds” for oral tracheal intubation. The Four Ds include distortion, disproportion, dentitions and dysmobility. A good way for a provider to assess the Four Ds is using the 3-3-2 technique, which includes 3 fingers breath between the incisors, 3 fingers from the hyoid bone to the chin and 2 fingers from the floor of the mouth to the top of the thyroid cartilage. The rule of thumb is the fewer the fingers, the straighter the blade. Imagine trying to get a big fat stick in an opening that’s barely wide enough to get the tongue through. Choosing the correct laryngoscope blade will help ensure that our efforts aren’t impeded by the tool.

Do you use the Mallampati scoring system when assessing the level of difficulty of an airway?

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Step four is selecting an intubation technique. The direct laryngoscope is a lever with a light at the end of it. Unlike a video laryngoscope, which enables users to capitalize on a superior glottic view and access provided by the video image, direct laryngoscopy doesn’t allow us to look around corners. Therefore, we must have a good understanding of the anatomy to correctly place and use it. The first obstacle that we must move with our lever is the tongue. We simply follow the center of the tongue with tip of the blade and gently lift as we advance, and the blade will naturally come to the vallecula at the base of the tongue. Simply pulling the tongue forward and down will displace the tongue and expose the laryngeal structures; veterinarians have been doing that for years to secure airways in large animals. Remember the laws of physics—every action has an equal and opposite reaction. This means that whatever you do with the handle of the blade will move the other end of the blade. Remember you can’t look around corners so trying to play seesaw or rocking back toward the teeth is only going to impede your view.

Anatomy Refresher

EMS Airway Expert Charlie Eisele shows the airway structures on a cross section of a plasticized cadaver head. Photo James Radcliffe

Relax & Recall Your Anatomy Lessons
Remember to work smarter, not harder. When I teach together with my flight medic friend of mine (the one who grades intubation difficulty in levels of fun), he always says, “Relax. Your most important decision in your shift is what’s for lunch. This will pass.”

So relax and take a deep breath. If you’re one of those folks who needs to take a death grip on the handle and your arm shakes when you intubate, try a pediatric handle and hold it with two fingers and your thumb toward the base of the blade. Great. Now imagine those ancient Egyptians again moving large stones with a lever. They didn’t move it by rocking back; they lifted up and forward. so place the laryngoscope blade at the base of the tongue and lift up and out to move it out of the field of view to visualize the laryngeal structures.

I tried every trick and gadget I could find for years, but they never seemed to work and all I did was get frustrated. I was told if you drop the head of the patient off the end of the stretcher or prop up the shoulders, it would make a better view—wrong. It wasn’t until I started to study the anatomy and consider what I was trying to accomplish that I realized that all I was doing was moving all the structures into my field of view, requiring me to move them even farther to get that good look at the larynx. However, if the patient’s condition will allow, then raise the head to bring the ears even with the chest, thus aligning the axes to allow for a better view.

Success Is As Easy As…
Finding your success is as easy as following this simple rule: Don’t block your view. Keep the blade at an angle to maximize the field of view by sweeping the tongue to the left and slightly turning the handle toward the left. Make sure when inserting the tube to keep the tube to the right side of the mouth, and watch the tip advance through the glottic opening. One technique for advancing the tube is the hook method, simply sliding the tube into the oral cavity from the right corner of the mouth.

If you understand the anatomy and the mechanics of direct laryngoscopy, your success rate will greatly improve. Remember that intubation is a finesse skill, not brute force, so relax and work smarter, not harder.

Be Safe,
Jim Radcliffe, MBA, BS, EMT-P

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Capnography’s Role in Traumatic Airway Intubation

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Does your system have specific protocols on managing ventilation of head-injured patients? Photo Courtesy Christopher T. Stephens, MD


Greetings colleagues,

To begin this last article in the three-part series on managing the traumatic airway, let’s review briefly what has been done at this point. Either you have successfully or unsuccessfully intubated your trauma patient, have gone for a supraglottic airway device or have chosen to hand ventilate the patient during transport with an oral/nasal airway and bag-valve mask (BVM).

The only other option is a surgical airway. We will briefly review these techniques but I warn that you MUST practice these on suitable mannequins or cadavers in a laboratory setting. Another alternative is to purchase some pig tracheas or similar and practice your surgical skills on these.

The point is that practice allows you to appreciate the anatomy and understand the skill. Most EMS protocols use a needle cricothyroidotomy technique in which the cricothyroid membrane is identified between the thyroid and cricoid cartilages. (I encourage you to identify this important landmark on yourself, then your family and friends, followed by practicing on your patients as part of your physical exam.) Once you’re comfortable finding this landmark on many people, it will come second nature in an emergency. Be certain that you’re familiar with the needle cric device/supplies that your system uses; once the needle is in place, either a wire is placed through it to allow for a trochar tracheostomy tube to be placed over the wire or the large bore catheter remains in place for ventilating with a BVM.

Again, however your service trains and uses this technique, be sure to cover it regularly with training. An alternate technique is the open surgical cricothyroidotomy, where a scalpel is used to make a vertical incision over the cricothyroid membrane to identify the membrane. Once identified, make a horizontal stab with the scalpel, followed by flipping the scalpel and placing the handle end in the incision and twisting 90 degrees to enlarge the opening.

At this point, there’s likely a fair amount of blood to deal with so make certain that your partner has suction and 4X4s to blot away the blood. Now you can do one of two things. You can go straight for a smaller endotracheal tube (ETT), such as a 6.0 or 6.5, and place it in the surgical opening. Or you can place a bougie intubating stylet into the opening so that you have something in the airway to guide your ETT over and into the trachea. This is a nice technique to use so that you don’t lose your surgical opening while trying to place the ETT into the hole. Try this on the cadaver, animal tracheas or appropriate mannequin. There are many ways to accomplish a surgical airway and these are some of the ways that we have found useful for teaching our local medics.

So now you have an airway to manage en route to the hospital. We will assume that you have an intubated patient from the case introduced in the first article of the series, “Managing the Traumatic Airway.” Once the tube is secured and you are ready for transport, be certain to re-assess the tube placement once packaged in the ambulance or aircraft. I still find many right mainstem intubations once delivered to me at the trauma center.

Once you’ve determined that the patient has bilateral breath sounds and equal chest expansion, take a quick look at your capnography monitor and pulse oximeter. Are you happy with the waveforms and numbers? These numbers can guide your therapy and airway management throughout transport. Is the patient on 100% FiO2? Be certain that oxygen is reaching the patient! Do you need to suction out the ETT? Make sure that you are able to adequately exchange gases via the ETT for your patient throughout transport.

This is where capnography is so valuable. If your patient still has a blood pressure and pulses, you should pay very close attention to your capnograph waveform. It will let you know if there’s an obstruction between your patient and the end of the ETT by the slope of the waveform. In addition, it will give you insight into your patient’s perfusion status. If a nice, normal waveform is present, then your patient is perfusing adequately enough for cellular respiration to take place.

Note: Your patient may still be in the early stages of shock, and you should always be vigilant for signs of continued blood loss. If your patient is in profound shock, in extremis or arresting, then your capnograph waveform will be distorted with low numbers. Again, this monitor is important for you to use and understand for your intubated patient management in the field. Please take the time to read about, practice and understand waveform capnography. Spend some time in the emergency department looking at ventilated patients who have capnography waveforms on the monitor. This will help you begin to understand the concepts of using this important monitor for sick patients.

If your patient has signs of a traumatic brain injury, what you do with your ventilation management becomes VERY important. You must maintain your end¬-tidal carbon dioxide numbers between 30–35 mmHG to prevent either hypo- or hyperventilation with subsequent cerebral perfusion abnormalities. Please read up on this and discuss with your medical director. Only patients showing signs of tentorial herniation should be mildly hyperventilated in the field, avoiding end tidals lower than 28 mmHg!

Poll Question: Does your system have specific protocols on managing ventilation of head-injured patients?

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If your system still isn’t using continuous capnography on your monitor, it will be important for you to at least monitor continuous pulse oximetry and end-tidal using a colorometric easy cap device during transport to ensure correct tube placement. We all need to aim for zero misplaced endotracheal tubes in the field. If there is ANY doubt, take the tube out! This is a very important concept. It’s much better to assist an airway with a BVM and oral/nasal airway (or a supraglottic device) than have a misplaced tube on arrival at the trauma center!

I hope that these articles have given you some tools to use in the field when faced with a trauma airway. Remember to read, discuss with colleagues and medical directors, and practice airway maneuvers whenever possible! A great place to start is by attending a cadaver airway lab in your area or sign up for one at a national conference. I wish each of you the best of luck in your EMS career and please feel free to contact me anytime with questions or concerns. I am here for all of you field providers! Work hard and do the very best for your patients.

Part I: Managing the Traumatic Airway
Part II: Trauma Airway Intubation Is a Team Effort

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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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When the Primary Assessment Requires Priority Care

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The focus of EMS remains bringing the severely injured trauma patient and physician together as quickly as possible. (Photo: Mark C. Ide)

She never saw the truck. She had just dropped the kids off at school and was hoping to run some errands before she had to be at work. She edged her Escort out of the school parking lot to make a left turn onto the four-lane, trying to see around the truck parked on the northbound shoulder. She pulled out, and an F-150 impacted the driver’s door on the Escort. The collision was over in micro-seconds, with both vehicles coming to rest in the southbound lane.

Start the clock.

’60 Precious Minutes’
The “Golden Hour” was first described by R Adams Cowley, MD, at the University of Maryland Medical Center in Baltimore.1 From his personal experiences and observations in post-World War II Europe, and then in Baltimore in the 1960s, Dr. Cowley recognized that the sooner trauma patients reached definitive care—particularly if they arrived within 60 minutes of being injured—the better their chance of survival.

Field hospitals, MASH units and medevac helicopters in the Korean and Vietnam Wars contributed to increasing survival rates. Improvements in medications, techniques and instruments were key to survival, but none of these were of any value if the patient remained separated from the surgeon.

Over the years, we’ve debated whether the Golden Hour is actually 60 minutes, but Dr. Cowley’s concept remains true. Thirty-eight years after Maryland State Police Helicopter 1 picked up its first patient on Falls Road in Baltimore County and delivered him to Dr. Cowley’s team, the focus of EMS remains bringing the severely injured trauma patient and physician together as quickly as possible.

In this effort, we’ve gone from “load and go” to “stay and play” and back again. The ideal level of street medicine versus scene time remains somewhere in the middle. Time spent on scene changes each year with the advent of new tools and techniques and the results of valid studies.

Our job in EMS is threefold: 1) get to the patient quickly, 2) fix what we can fix and 3) quickly get the patient to the right hospital. Anything we can do to compress each of these time periods is good for the patient. We’ve known this in the traumatically injured, and now we use it for STEMI and stroke patients; more are sure to follow.

At 12 Minutes
She was unconscious and unresponsive when the medic unit arrived. Her head slumped to the side and frothy blood came from her mouth with each shallow breath. While Rescue Squad 7 worked to free her, the medics brought her head into neutral alignment and tried to open her airway. With a clenched jaw and obvious facial fractures, both an oropharyngeal airway (OPA) and naso­pharyngeal airway (NPA) were out of the question. Working together, the medics used a bag-valve mask, suction and cricoid pressure to optimize oxygenation and ventilation.

LOC: Unconscious; grimace to sternal rub with an occasional moan; GCS 6. Airway: Compromised by clenched jaw, poor gag reflex, blood in mouth. Breathing: Respirations shallow and rapid; frothy blood present; breath sounds full on right and slightly diminished on left; crepitus on left. Circulation: Radial pulse strong, regular, rapid; no major external bleeding noted. Vitals: HR 144, RR 42, BP 112/62, SaO2 85%.

It’s About Perfusion
I used to use the term “airway management,” but the words seem to imply our job is done when we successfully get air through the glottis and into the lungs. I tried “respiratory management.” Yes, that’s it; secure an air passage, inflate and deflate the lungs. No, that’s not it either.

I’ve settled, for now at least, on “perfusion management.” Our lifesaving job is to return and maintain our patient’s cellular perfusion, and then get them promptly to the right facility.

How are the Golden Hour and perfusion management related? Without prudent management of both, we fail our patient. Almost every lifesaving intervention we perform has to do with establishing or maintaining cellular perfusion. An AED allows the heart to return to a perfusing rhythm. Allowing the hypotensive patient to breathe on their own instead of paralyzing them encourages blood return to central circulation. Decompressing the chest, stopping bleeding, capturing the airway and ventilating patients with poor oxygen saturation all improves perfusion.

So, in the field, the burden of responsibility is on us. With the critically sick or injured patient, we must look at on-scene interventions with a cynical eye. Does the procedure enhance perfusion? Must it be done now?

Prehospital Intubation—A Good Thing, Sometimes
We’ve all read and heard that paramedics shouldn’t intubate: “It’s a skill better left for those in the hospital.” But field intubation is a good thing. It secures our patient’s airway. It allows us to properly oxygenate and ventilate patients. It’s usually completed swiftly and appropriately.

But field intubation can be a bad thing. When we make poor decisions and fail to execute the skills we were taught, we extend scene time and create hypoxic patients. When we fail to give post-intubation management the proper attention, it leads to unrecognized misplaced tubes, inappropriate ventilation and poor oxygenation.

We intubate patients in the prehospital environment for three primary reasons: 1) establish and maintain an airway, 2) normalize oxygenation, and 3) establish appropriate ventilation.2 Although field intubation can be a good thing for the patient, it’s not always the right thing for them.

So, when do you intubate the patient? When it will make them better or keep them from getting worse. Do you intubate at the scene or during transport? Both. We should intubate when it’s most appropriate. Consider these factors:

  • How sick is your patient? Is the airway patent? What is their level of oxygen saturation? Are they adequately ventilated? Will they survive transport without intubation?
  • What’s your transport time? If scene time exceeds transport time, will the intubation make a difference? Is good BLS and rapid transport a better option?
  • What’s your intubation skill and experience? Do you have the resources and skills necessary? How are you making decisions—with your head or your ego?

If you get the patient to the hospital bagging them to sats of 96% with an OPA in place and no gastric inflation, you’re my perfusion management hero. Ditto if you do it with an ET tube. But if you spend 20 minutes on scene, rooting and digging in a patient’s throat, making multiple intubation attempts and letting their sats drop to 85%, we need to have a talk. “Do what’s best for the patient,” says Maryland State Aeromedical Director Douglas Floccare, MD, “and you can’t go wrong.”2

What if it’s a difficult tube? Some of my colleagues say that the difficult intubation is the typical intubation, and an easy intubation is a gift. They’re right. Anything that precludes our ability to see the cords or pass the tube has been broadly defined as a “difficult laryngoscopy” or “difficult intubation.”3

Studies on the frequency of difficult intubations are almost completely limited to operating room (OR) or intensive care unit (ICU) patients. The number of studies regarding EMS and ED intubations pales drastically in comparison. Those that have been done focus primarily on the rate of undetected esophageal intubations received at EDs and complications associated with intubations done outside the OR.

Until we have studies that focus on difficult intubations in the prehospital arena, we have to rely on these OR and ICU reports. Do the results of these studies reveal poor intubation technique or poor post-intubation management? Are poor intubation outcomes the result of training, technique, tools, experience or conditions? And do these factors negatively affect the time to definitive care?

At 32 Minutes
The helicopter landed as the patient was freed from the car and moved to the medic unit. It was a 42-minute drive to the only hospital in the county or an 18-minute flight to the trauma center. Seemed like an easy choice, but she was now incredibly combative, so much so that the crew could hardly secure her to the backboard let alone safely fly her out.

As the minutes ticked away, the easy choice was becoming a tough decision. Tough, until the senior paramedic on scene was able to get an 18 gauge IV?in the patient’s hand; holding it securely as lidocaine, etomidate and succinylcholine were pushed.

The intubation was performed using a GlideScope® Ranger video laryngoscope, with a clear view on first attempt. Her sats rose to 98% and EtCO2 to 35. She was secured to the board and loaded in the aircraft. As the succinylcholine wore off, the two helicopter paramedics assisted her ventilations enough to maintain high sats, but didn’t over-ventilate her and drive blood from her central circulation.

Now Versus Next
I’m a dinosaur. I look at new technology with a suspicious eye. I see no reason to change for the sake of change. For instance, I finally purchased a PDA cell phone recently, and I realized what everyone seems to have known for years—they’re amazing.

The first time I saw a video laryngoscope, I felt much the same way I initially did about the PDA: That’s a lot of money for a camera and some lights. I also thought, I’ve done just fine with my bent metal stick for the past two decades, why should I change now? However, having used the device, I know why. Because it’s a better way to deliver patient care, with less opportunity for physical trauma to the patient, quicker visualization of the glottis and enhanced verification of endotracheal tube placement.

Straight or curved direct laryngoscopy blades are de­signed to move the anatomy to obtain a line-of-sight glottic view. Head-neck manipulation, tongue displacement, direct contact with laryngeal structures, and impacting teeth are all opportunities to injure a patient.

Unlike classic laryngoscope blades, video laryngoscope blades are shaped to match the pharyngeal anatomy. The acute blade angle allows the blade’s tip (and camera) to follow the patient’s anatomy to view the glottis. Multiple studies have found that 20­–40 lbs. of force is required during direct laryngoscopy, and it takes about 45 lbs. of pressure to fracture a tooth during laryngoscopy.4,5 My own, purely subjective, experience with video laryngoscopy is that much less force is needed to obtain a glottic view. I’d like to see studies that validate or dispute my experience.

If you’ve ever had to do a belly flop on the ground to see the cords of a patient, you’ll appreciate video laryngoscopy. The blade goes in the patient’s mouth and the video monitor is placed where you can see it. This makes visualization easier in a moving ambulance or helicopter, and has the potential to save scene time by allowing you to intubate easier during transport. The image on the monitor is larger than the view afforded by direct visualization. The clear detail provided on the screen allows for confident and quick landmark identification.

So, what’s the role of video laryngoscopy in prehospital medicine? Time for my predictions. It will become the standard of care, just like AEDs and 12-lead monitors. When our EMS children visit us in nursing homes, we’ll tell them tales of wasting precious minutes lying on the floor of someone’s home, using a light bulb and a metal stick to intubate patients.

At 65 Minutes
The aircraft settled onto the roof, and its rotors slowed to flight idle. She was moved to the waiting stretcher and then down the elevator to the trauma room. Masked, gowned and gloved, the trauma team swarmed around her—65 minutes from impact to surgeon.

 

Conclusion
For video laryngoscopy to truly enter the world of prehospital medicine, a paradigm shift must occur—a shift away from direct visualization. Cliff Boehm, MD, an attending anesthesiologist and assistant professor of trauma anesthesiology at the R Adams Cowley Shock Trauma Center, describes how it worked in his department: “There used to be two camps when direct laryngoscopy failed: the Bullard (rigid fiber-optic laryngoscope) and the LMA (laryngeal mask airway). Now there’s pretty much one camp—video laryngoscopy.”

Boehm adds that when video laryngoscopy first appeared as an anesthesia tool in his department, “that camera thing” was used when all other means failed. He and his colleagues now routinely use their GlideScope units as first-line tools, not just as a backup.6

As video laryngoscopy continues to evolve, I’d like to see the ability to digitally record images for QA, patient records and education. I’d like to see the camera and light in a standalone handle, and the image beamed to the multi-function display on our vital signs monitor. Better yet, maybe we could have it recorded on our monitor and also transmitted to the heads-up display on our safety glasses, so we can view the glottis and simultaneously see the patient’s heart rate and oxygen saturation.
We live at an incredibly exciting time in history, especially in medicine. Da Vinci robotic surgery, STEMI intervention, laparoscopic surgery and a multitude of other tools and procedures are developed each week. Video laryngoscopy is one of them. It’s a great tool for us in medicine, and it’s an important tool for our patients.

Although I’m not ready to put my 4 Mac or 3 Miller on eBay, I can’t wait to see what awaits us.

Disclosure: The author has received no monetary support from Verathon Inc. He has received support from Verathon in the form of a video laryngoscope for evaluation and research purposes.

References

  1. Franklin F, Doelp A: Shock-Trauma. St. Martin’s Press: New York City, N.Y., 1980.
  2. Douglas Floccare, MD, Maryland State Aeromedical Director. Personal communication, 2004–2008.
  3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: “Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.” Anesthesiology. 98(5):1269–1277, 2003.
  4. Givol N, Gershtansky Y, Halamish-Shani T, et al: “Perianesthetic dental injuries: Analysis of incident reports.” Journal of Clinical Anesthesia. 16(3):173–176, 2004.
  5. Ghabash MB, Matta MS, Mehanna CB: “Prevention of dental trauma during endotracheal intubation.” Anesthesia and Analgesia. 84(1):230–231, 1997.
  6. Clifford Boehm, MD, Assistant Professor of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Personal communication, 2008.

Reprinted from JEMS Vol. 33, Issue 9 with the permission of Elsevier Inc., copyright 2008. For more information or to subscribe, visit www.jems.com.

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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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