Tag Archive | "video laryngoscope"

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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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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GlideScope Video Laryngoscope Celebrates 10th Anniversary

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BOTHELL, Wash. — The GlideScope video laryngoscope, invented by Canadian vascular surgeon Dr. Jack Pacey and manufactured in Vancouver, B.C. is celebrating its tenth anniversary in 2011. A celebration was held on April 21st at the company’s new state of the art manufacturing facility in Burnaby, B.C.

Since its introduction, the GlideScope brand has forged the path for an entirely new category of airway devices; the video laryngoscope (VL) class. A widely used “go to” device for Anesthesiology, Critical Care, Emergency, EMS and Military health care providers, the GlideScope provides a consistently clear view of the airway, enabling quick intubation.

Unlike a direct laryngoscope (DL) which may not always provide a clear airway view, resulting in a “blind” procedure, the GlideScope consistently provides a clear picture of the larynx and vocal cords on the display monitor, offering visual control of the endotracheal tube (ETT) in its trajectory toward the airway. With an integrated camera and anti-fogging mechanism providing an excellent viewing range, and “blades” in multiple patient sizes, in both reusable and single-use forms, the GlideScope facilitates fast, accurate ETT placement.

“We’re extremely gratified that the GlideScope has helped save lives over the past ten years,” stated Dr. Jack Pacey, President of Verathon Medical Canada and inventor of the device. “And we’re very proud that our Canada employees and operations have been at the center of this major innovation in airway management worldwide.”

Traditional direct laryngoscopes have been widely used since WWII. However, they frequently require “line of sight” maneuvers which can induce neck flexion, head extension, laryngeal depression and other stress related movements. In late 1999, Dr. Pacey, in his capacity as a vascular surgeon, recognized a clear need for improvement in anesthesia intubations.

In his basement workshop, Dr. Pacey integrated imaging technology with laryngoscopy, to provide reliable visualization and procedural access space to aid in the intubation of difficult airways. The pioneering work of Dr. Pacey and his team in Canada resulted in the introduction of the innovative GlideScope video laryngoscope in 2001.

With the extensive adoption of this significant innovation in the field of airway management, video laryngoscopy has now become a routine practice in health care facilities around the globe. In addition to Anesthesiologists and Intensivists, it is actively used by EMS and military teams worldwide. It also has been featured in the well know television show, “ER” (NBC) and “Royal Pains” (USA Network).

Dr. Pacey continues to lead a dynamic team in Burnaby, including manufacturing the popular GlideScope and engineering new healthcare solutions.

About Verathon Inc
Verathon designs and manufactures reliable, state-of-the-art medical devices and services that offer a meaningful improvement in patient care to the health care community. The company’s noninvasive BladderScan instrument is a standard of care for portable ultrasound bladder volume measurement. The brand is found in over 60 countries in Urology and Primary Care practices, as well as Acute and Extended Care facilities. With the acquisition of Saturn Biomedical Systems in Vancouver, Canada, Verathon entered Anesthesiology, Critical Care and Emergency markets with the GlideScope video laryngoscope brand. Verathon is headquartered in Bothell, Washington and operates as a subsidiary of Roper Industries. For more information, please visit verathon.com.

Click here for video interviews of Dr. Pacey and tips for using the Glidescope.

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‘Grounded’ Care

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Visualizing the airway in a burn patient

By Marvin Wayne, MD, FACEP, FAAEM

Airway management is a basic and essential skill of anyone caring for an injured or a seriously ill patient. Although many patients can be managed with a non-invasive airway, many benefit from endotracheal intubation.

Much has been written about the hazards of endotracheal intubation, even in this latter patient group. Paralytics have been suggested, and utilized, by some ground and air EMS systems, but concern has arisen over the ability of crews to achieve effective intubation even with paralytics.

One study, for example, showed esophageal intubation rates for all patients as high as 25%.(1) The challenge for prehospital advanced life support (ALS) providers, then, is achieving a balance between the need for intubation and safely achieving that intubation.

Even in the most controlled circumstances, endotracheal intubation can be challenging. Although the addition of routine end-tidal CO2 (EtCO2) monitoring has reduced the incidence of esophageal intubation, it does not reduce the difficulty of the prehospital intubation process. In the field, poor lighting conditions, bad weather, the physical location of the patient, injuries to the neck and spine, and variations in skill levels of the operators contribute to that difficulty. But new technology may be able to provide some, if not all, of the solution to that dichotomy.(2)

The goal of any new airway technology should be to reduce multiple attempts at intubation, as well as prevent dental, mouth and airway trauma, desaturation, intracranial hypertension, pneumothorax, pulmonary aspiration and even iatrogenic death from an unrecognized esophageal placement.(2)

The Advent of Video Laryngoscopy
For many years, direct laryngoscopy (DL) has been the gold standard by which to achieve intubation, performed with either curved or straight laryngoscope blades. However, DL often yields surprisingly poor laryngeal views. Alternatives have been explored, but most have proved to be difficult to master, time consuming, unreliable and costly. Even rigid fiber-optic laryngoscopes—the technology on which “modern” DL is based—hasn’t been widely used, despite its advantages. What has been needed is a device that provides a full view of the glottic airway during laryngoscopy and is easy to learn and master by medical personnel who may or may not frequently perform intubations.

A significant advance took place in this realm when the video laryngoscope (VL) was developed for use in the surgical suite. These devices have a camera lens incorporated into the handle or blade, allowing the image of the larynx/glottis to be displayed on a monitor that’s either directly attached to, or separate from, the blade/camera system. The ability to see the larynx while intubating, even in the most difficult patients, as well as being able to use the monitor as a teaching tool, are recognized as important advancements in airway management.

Although many of these devices (i.e., McGrath Series 5 from LMA North America, TruView from Truphatek, Storz DCI, AWS-S100 from PENTAX Medical Co., Video Macintosh Intubating Laryngoscope System from Volpi AG and GlideScope® from Verathon Medical®) have proved their worth in the hospital setting, a new design was necessary for use in the prehospital environment. This new device would have to be rugged, small and easy to manipulate when working in difficult field conditions.

Currently, the only product on the market that we believe meets all of the criteria for
use in the prehospital environment is the compact GlideScope Ranger.

The Ranger has a digital camera lens incorporated into the center (versus the tip) of its specialized blade, which allows a wider view of the vocal cords on its monitor. A unique anti-fogging technology provides an unobstructed view of the larynx throughout the entire process of tube placement, a feature that’s especially valuable during emergency intubation. It weighs less than 2 lbs. and is engineered to be dependable in a variety of challenging field conditions, including very high or low temperatures, high humidity, and high altitude.

The Ranger is powered by a rechargeable lithium battery, which provides a minimum of 90 minutes of continuous use. A rigid stylet aids in the control of the endotracheal tube (ETT) as it enters the larynx. The blade has a 60º curvature in the midline to match anatomical alignment, so it doesn’t require a “line of sight” for a good view. The high-resolution color display monitor provides a clear picture of the larynx and vocal cords even in bright light, which, again, transforms it into a valuable teaching tool.

There appear to be special benefits to the GlideScope Ranger for trauma patients with limited mouth opening or in cervical immobilization.(3) Very little force is required to expose the glottic opening with the blade so manipulation of the head and neck is reduced. It also functions well in situations where blood or other fluids are present, in mildly obese patients, and because direct visualization of the glottis is unnecessary during intubation, the GlideScope Ranger is less stimulating, an advantage for use in semi-awake patients.

A New Technique
The manner in which tracheal intubation is performed with the GlideScope is unique to its design. The handle is held in the left hand in the same way that one would hold a standard laryngoscope, while the blade is inserted between the teeth under direct vision. It’s important to start out in the midline of the tongue and to stay on the midline. (There’s no need to sweep the tongue out of the way, as is usually the practice with conventional laryngoscopes.)

When the uniquely curved blade passes the teeth, the clinician can now follow the landmarks on the video monitor proceed to the larynx. Identifying the glottis is generally easy. The only technical difficulty with the GlideScope may be guiding the ETT toward the image of the glottis seen on the screen. This difficulty is encountered because the camera is directed (by design) at a 60º angle.

The manufacturer recommends bending the ET tube to conform to the shape of the blade for a gentle curve of 60º. Still, the angle by which one inserts the tube is quite steep. A special stylet developed to lessen the difficulty of passing the tube into the trachea is available, but if advancing the tube presents a problem, withdrawing the GlideScope 1–2 cm will allow the larynx to drop down and reduce the angle required to insert it correctly.

The main limitation of the GlideScope is that there may be a physical resistance in the advancement of the ET tube; with a little practice this limitation is easily overcome. But once familiar with the steep angle of approach, the device is extremely easy to handle.

Case Reports
The following are examples from Whatcom (Wash.) Medic One of the type of cases in which the GlideScope Ranger may be extremely useful.

Case 1: EMS responded to a conscious 57-year-old female, a victim of a fire that started in her home. She had second-degree burns on her legs, buttocks and thighs greater than 30% of her body. She had redness of her face, but no obvious singeing of nares. There were questionable particulates in her oral cavity, but no voice change. Pulse oximetry was 93% on room air, rising to 95% on oxygen given by non-rebreather (NRB) mask. The patient had a history of smoking one pack per day. Respiratory rate was 30 but appeared unlabored. Blood pressure was 130/90, heart rate was 110. She was awake and talking.

Because she was 25 miles from a community hospital and 100 miles from a burn center, and although a major airway burn was not expected, it was elected to provide rapid sequence intubation (RSI) as a precaution prior to helicopter transport to the burn center. RSI was conducted, and the GlideScope Ranger was used to visualize the airway.

Surprisingly, the crew found she had soot in her pyriform sinuses, edema of her glottic opening and significant erythema of the entire region. The GlideScope made possible a quick (18 seconds) and easy intubation, and the video monitor provided an excellent teaching opportunity the prehospital personnel involved. In addition to direct visualization, EtCO2 further confirmed correct tube placement.

Case 2: EMS responded to a 60-year-old male in severe respiratory distress. He was in the bedroom of a manufactured home. He suffered from severe Pickwickian syndrome related to morbid obesity, and had a body mass index (BMI) of 43. (His weight was approximately 656 lbs).

He was obtundent and had a pulse ox of 85%. Blood pressure could not be obtained in the patient’s current position, and moving the patient would require assistance that was not available at the time. His respiratory rate was 40, shallow and labored. Oxygen by NRB mask did not improve his condition.

In light of further deterioration, intubation was the only alternative. However, his BMI and body habitus were going to make it a difficult intubation. He was sedated with midazolam and, using the Ranger, was intubated within 26 seconds. Despite limited mouth opening and a difficult position, tube passage was assured via excellent visualization of his vocal chords.

Case 3: EMS responded to a 67-year-old male in cardiac arrest found in an alley behind a tavern. It was 2 a.m. and raining, and he was difficult to get to because vehicle access was blocked by construction in the area. The first responding basic life support (BLS) unit started CPR with bag-mask ventilation (BMV) performed with extreme difficulty.

The patient had vomited copious amounts of stomach contents. The AED showed that no shock was indicated. After suctioning the oral cavity, intubation was performed with the Ranger in 33 seconds. Tube placement was confirmed by direct visualization on the GlideScope monitor and EtCO2. The patient, who had probably sustained a primary respiratory arrest, was successfully resuscitated.

Case 4: EMS responded to a car struck by a semitruck at high speed. The driver of the car was trapped in the vehicle and had significant craniofacial trauma. His airway was compromised, and he had agonal respiration. To extricate him, extensive rescue operations were required.

A paramedic was able to intubate the patient from the open windshield using a Ranger with the blade of the laryngoscope reversed. It took two attempts and 42 seconds to place the tube, with suctioning required after the first attempt. Confirmation of tube placement was done via direct visualization on the GlideScope monitor and EtCO2.

These case reports demonstrate the capabilities of a video laryngoscope, now available to EMS personnel, in performing emergency intubation. In the first case, without video visualization it would have been difficult to diagnose the glottic swelling that was unsuspected on initial examination. In the second case, this high-BMI patient with complex anatomy might not have been able to have any airway achieved. In the third, a dark night, aspiration and other factors made any airway extremely difficult. And in the fourth, it’s unlikely the intubation could have taken place at all until the patient was extricated from the vehicle.

The ability to successfully intubate critical patients in the field, especially those who present with difficult airways for a variety of reasons, is an important advancement in emergency airway management.

The Impact on Prehospital Care
The potential impact of video laryngoscopy on prehospital medicine may be significant, especially for ground services that are often faced with difficult airways and air medical personnel who must work in tight quarters while airborne.

As previously mentioned, field intubations are by definition fraught with potential complications, such as esophageal intubation, pneumothorax, reduced ventilation and oxygenation, and pulmonary aspiration.(2) Because of the ability to visualize the airway without distortion from fogging to, in effect, “see around the corner,” many of these complications can be avoided.

One study looked at Cormack-Lehane ratings (Grades 1–1V) of those obtained with the GlideScope in 15 patients with cervical collars.(4) The Cormack grading in 14 of the 15 patients (93%) was reduced by one when using the GlideScope. Five Grade I1 patients became Grade 1 using the GlideScope. The average time of intubation with the GlideScope was 38 seconds without complications, including any damage to the teeth. This improvement in visualization of the glottis during intubation is a major factor in the conclusion of some that direct laryngoscopy for emergency intubation will become a relic.(2,3)

The GlideScope has also become the method of choice for many in training of airway management.(5) Currently, Whatcom Medic One is conducting a crossover study of video camera-assisted intubation versus traditional laryngoscopy. Although preliminary data is encouraging, many questions remain to be answered. These include cost versus benefit and skill maintenance of the traditional technique when a camera system isn’t available. Time and the marketplace, we believe, will help answer those questions. However, a new era of airway management may soon be on all of our horizons.

References
1. Katz SJ, Falk JL: “Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.” Annals of Emergency Medicine. 37(1):32–37, 2001.
2. Rao BK, Singh VK, Ray Sumit, et al: “Airway management in trauma.” Indian Journal of Critical Care Medicine. 8(2): 98–105, 2004.
3. Rose DK, Cohen MM: “The airway: Problems and predictions in 18,500 patients.” Canadian Journal of Anaesthesia. 41(5 pt 1):372–383, 1994.
4. Sakles J: “The GlideScope Video Laryngoscope: A practical guide to the future of airway management.” Emergency Medicine and Critical Care Review. 2(1):34–35, 2006.
5. Agrò F, Barzoi G, Montecchia F: “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” British Journal of Anaesthesia. 90(5):705–706, 2003.
6. Rai MR, Dering A, Verghese C: “The GlideScope System: A clinical assessment of performance.” Anaesthesia 60(1):60–64, 2005.

Disclosure: The author has received no monetary support from Verathon Inc. His EMS system, Bellingham/Whatcom County, Wash., has received support from Verathon in the form of four video laryngoscopes for evaluation and research purposes.

This article was originally published in The Perfect View.

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