Tag Archive | "video laryngoscopy"

Scary Airways

Tags: , , , , , , ,


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?

View Results

Loading ... Loading ...

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

Post to Twitter

See Cords Around Corners

Tags: , , ,


I knew it was going to be a tough intubation. He was a bear of a man, well over 300 pounds. But compounding the problem was his tiny mouth and diminutive jaw—barely enough mandible to catch on the top of his C-collar. Respirations were agonal and sats were on the verge of precipitous decline. As I scissorred open the teeth, I was dreading the expected view of redundant tissue, blood and saliva, and hoping for the elusive larynx.

The adult Glidescope blades come in two sizes, a 3 and a 4. The 4 is what I use for nearly all adults and is listed as 90 pounds and up. Image Courtesy Graham Snyder, MD

I placed the 4 Mac into the mouth, but it was not good. The man’s jaw and mouth were barely large enough to place the blade between the teeth, yet his tongue seemed gargantuan. The thickness of his torso plus the very real fear of worsening a possible c-spine injury resulted in a view of only a pink wall of tissue.

“Want me to get the scope?” queried the respiratory therapist.

“This is not a candidate; there’s too much blood,” I responded, envisioning the futility of attempting to snake a tiny flexible fiberoptic wire through the patient’s nose or into his mouth–the tissue compressed flat in his supine position and the tiniest droplet of blood or saliva leading to complete loss of view.

“Not the flexible fiberscope, the video laryngoscope,” The respiratory therapist clarified as he placed the plastic blade in my hand and turned the video screen in my direction.

I had picked up the Glidescope a number of times at conferences when walking by promotional booths. On a dry plastic mannequin head, it seemed to work spectacularly. The view of the cords was superior to all but the easiest of direct laryngoscopy, and the force needed to obtain that view was a fraction of that needed normally.

But would it work in a high-pressure, high-stakes clinical setting?

The patient was difficult to bag so I had about 60 seconds before I would need a rescue device or proceed to cricothyroidotomy.

I gently inserted the blade sliding down the center of the tongue and in seconds was greeted with a textbook view of not only the larynx, but the arytenoids and the aryepiglottic folds as well! There was four times the amount of information I needed to place an ET tube normally. I grabbed the endotracheal tube, which the RT had preloaded on the strange glidescope stylet, not knowing that my challenge had just begun.

For the past 11 years, I’ve been giving lectures on management of the difficult airway to the right students at the wrong time in their career. Learning direct laryngoscopy and effective placement of an endotracheal tube is a challenge in itself. When you add the extreme stress and anxiety of a horrifically unstable patient, it’s a wonder we can pull it off at all. However, with the combination of good lectures, operating room and/or simulation time, we all learn the art. Once you become proficient, in truth, it’s not that hard…except when it is.

The majority of difficult airways occur because of an inability to visualize the vocal cords. Usually, this is not a surprise. The causes are innumerable and sometimes additive. Even before beginning the procedure, when a patient has a small mouth, a large tongue, and a short jaw, you should anticipate a difficult airway and make plans for managing it.

There are plenty of other options, including lighted stylets, retrograde intubation and LMAs. The most important thing is that you be well practiced in the technique so that when the time comes, when the stakes are the highest, you are relaxed, confident and proficient.

This is just as true when using video laryngoscopy, and is often ignored because at first glance it seems both very similar in the technique we are all confident in (direct laryngoscopy) and is easier than direct laryngoscopy. This is true, BUT if you do not make the appropriate modifications to your technique, you will at best struggle and at worst have a failed airway.

Video laryngoscopes allow for spectacular visualization of the larynx often in cases where direct laryngoscopy would be extremely difficulty or impossible. This is best demonstrated by a patient with a small mouth and big tongue, which unfortunately is the case with all infants.

The magic of the Glidescope is you do not have to physically look in the mouth (only at the video screen), so intubation can still be accomplished on these tiny airways as demonstrated below in this 16-month infant simulator. See the video and photograph below.

Intubation can still be accomplished on tiny airways, as demonstrated in this 16-month infant simulator. Photo Courtesy Graham Snyder, MD

Click here for video.

Step 1: Know your Equipment.
There are a variety of different video laryngoscopes, each of which have its own unique performance characteristics. At our institution, we use the Glidescope Ranger. But no matter what you use, you must learn the unique geometry of the blades and significantly different techniques for intubation before the time of crisis. This can be accomplished with a stable patient and bedside supervision with an experienced practitioner—and ideally complemented by both supervised and independent practice using human patient simulators or airway task trainers.

Step 2: Assemble the Equipment Correctly.
There are really only three pieces of equipment. The wand (light source and fiberoptic camera), the plastic blade cover and the video screen. The wand plugs into the video screen intuitively and then the blade cover slides onto the wand with a definitive click. The wand must go in straight into the plastic sheath. If the wand is placed into the blade cover rotating 90 degrees, the screen will be 90 degrees off but in addition there will be extremely distracting glare. Make sure that the writing on the blade cover aligns with the writing on the wand. If you don’t, when you look in the mouth you will not be able to tell whether the blurry spots on the video screen are from saliva obscuring the view or from the plastic refracting.

Step 3: Don’t Look in the Mouth.
The Glidescope looks very similar to a Macintosh laryngoscope, leading people to mistakenly attempt to use it as one but everything is different. For one, the basic maneuver is more of a gentle straight up lift than the diagonal forward movement used in direct laryngoscopy. Also, much more importantly, getting the camera to find the cords has nothing to do with the maneuver needed to directly visualize the cords. Keep your eyes on the camera once you are inside the mouth and guide the video screen toward the cords.

Step 4: Use the Steel Stylet that Comes with the Glidecope.
You will be advancing the tube around and over the tongue and must maintain the curve of the original stylet or else the tube will not be able to find the larynx. If you use a normal stylet, it will get straightened out by the time you get to the larynx and will repeatedly, (and extraordinarily frustratingly) pass into the esophagus. You will no longer have the angle needed to pass into the cords.

Correct Technique

Incorrect Technique

Step 5: Don’t Get too Close to the Cords.
The temptation when using the Glidescope (because you obtain such a gorgeous video of the cords) is to press the camera close to the larynx. If the larynx fills the entire video screen, then the tip of your blade is millimeters away from the larynx. However, wherever the camera is, the tube will come in just below that point so if you’re abutting the cords already, when you pass the tube it will pass just below the cords (into the esophagus). If, however, you back away a little from the cords, then, because of the angle of the stylet, once the tube passes in front of the blade it will angle up and smoothly in between the cords.

Incorrect Technique

Correct Technique

Step 6: Back the Stylet out while Advancing the Tube.
The stylet is quite rigid steel and has nearly a 90-degree curve in it. This works perfectly for making the turn around the tongue and effortlessly going through the cords. However, since the trachea does not have a curve in it, as soon as the tip of the tube is placed between the cords, the stylet must be backed out to allow it to pass. Conveniently, there is a little flip top on the end of the stylet perfectly positioned for your thumb to kick it back and the tube to slide into the trachea. This is not optional. It is physically impossible to pass the tube with the stylet in place, so once the tip is between the cords, you or your assistant must remove the stylet.

Remove the stylet to secue the airway. Photo Courtesy Graham Snyder, MD

Conclusion
In my difficult case, once I took the respiratory therapist’s suggestion, I found the trauma patient’s vocal cords in seconds and with a sigh of relief advanced the tip of the orotracheal tube between the cords. I was puzzled briefly by the resistance I felt when I attempted to advance the tube, when the paramedic who brought the patient in (who was also watching the screen) reminded me, “You have to remove the stylet or it won’t advance.” He leaned forward, and like lighting a Zippo, he flicked the stylet lever (see image at left) backwards and the tube effortlessly advanced securing the airway.

When properly used, the video laryngoscope can transform extremely difficult intubations into nearly effortless lifesaving maneuvers and can be used in easy intubations as a safe and controlled way to teach the art and the science of orotracheal intubation.

Post to Twitter

Graham E. Snyder, MD FACEP

Graham E. Snyder, MD, FACEP, is medical director for the Center for Innovative Learning at WakeMed Health and Hospitals.

More Posts

Airway Finesse

Tags: , , , , , , , , , ,


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?

View Results

Loading ... Loading ...

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?

View Results

Loading ... Loading ...

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

Post to Twitter

The Five Ws of Intubation

Tags: , , , , , , , , , , , , , ,


Ask yourself “w” questions (i.e., who, what, when, where and why) when starting an intubation. Photo iStockPhoto.com

We learned that airway comes first in the very first class all of us took in EMS. Up until the recent changes in the American Heart Association guidelines, we had the following mantra stuck in our heads: “Annie, Annie, are you OK?” We were to open the airway, then look, listen and feel. So when it comes to managing the airway in the field, this is the first priority and often the most overwhelming to EMS providers.

Airways can be simple or complex depending on the particular patient, the environment and the experience of the provider. The gold standard for a secure airway, however, the ultimate goal is oxygenation with successful first-time insertion of the endotracheal tube (ETT).We reserve the ETT for a particular patient population in the EMS community. Let’s call them the “who.”

Who & When
The “who or “when” would be those patients who are unable to protect their own airways, who are apneic or who require ventilator support—either manually or by ventilator.

In some cases, selecting this group is obvious. If they can’t breathe on their own, then someone or something needs to do it for them. In other patients, it’s a little harder to determine whether we need to intervene with the airway. This is where we providers need to read the signs or look at tea leaves for guidance. We find signs in our assessment with things like rate and quality of respiration, end-tidal CO2, skin color, work of breathing and pulse oximetry. And sometimes, you’ve gotta ask yourself, “What are the voices telling me?”

Sometimes we providers become a bit anxious, regardless of our level of certifications, licensure or experience, about placing an ETT and controlling a patient’s ability to breathe spontaneously. A good example of this is the provider that doesn’t have the correct medications or the experience to perform a rapid sequence intubation (RSI) on a patient, so they attempt to “snow” the patient with narcotics or try to muscle past the patient’s gag reflex. We’re all guilty of this in some form or fashion at some point in our careers. I sometimes hear providers (including physicians) say, “I did the best with what I had.” Is this really our best? Maybe looking at other options and supportive care that is more time consuming, less glorious and in the best interest of the patient would be the better choice.

What
“What” are we really attempting to do when we intubate using direct laryngoscopy? The simple explanation would be to place a tube into the patient’s trachea to allow for ventilation. This is easier said than done. It’s simple enough in concept but requires us to displace the anatomy that stands between the oral opening and the trachea. Part of this challenge is m the largest obstacle in the airway—the tongue. We need to move it out of the visual field to be able to see the laryngeal structures. Usually when you encounter that huge floppy tongue, there’s a big floppy epiglottis attached to the base of it. If you don’t see it right away, look in the pool of pizza, beans and beer oozing out of the airway, lying in the back of the posterior oral pharynx.

What's the structure at the base of the tongue that prevents aspiration?

View Results

Loading ... Loading ...

Complicating the patient’s own anatomy is the fact that we’re trying to place a large metal stick in this small space and make enough room to guide the ETT through it to the trachea without inadvertently placing it in the esophagus. If we understand the anatomical structures and how they move, we can use that to successfully manipulate the airway.

One of the most common mistakes I see is when providers attempt to pry with the laryngoyscope blade as opposed to lifting the structures. Remember that the structures we’re attempting to displace are still attached to the patient by a large hinge joint known as the jaw, or mandible. If we displace the jaw, the soft structures attached will follow. This holds true for correct manipulation as well as incorrect ones. If we pry back toward the patient’s head, then all the structures we’re attempting to move out of our way are simply coming up in our face. You may hear this referred to as rocking or prying. It’s often associated with contact with the teeth and pulling the oral opening closed.

The most common cause of that is holding high on the laryngoscope handle and using the 90-degree angle of the handle and blade as the fulcrum and rocking back. Remember basic physics from high school? “Every action has an equal and opposite reaction.” If you’re pulling back on the stick, the other end of the stick is going to react as well and pull the structures right into your view. If we lift the stick up and away, say toward the corner of the ceiling, the jaw will lift and the tongue and epiglottis will follow.

Where
“Where” makes a difference—whether it’s on the cot, in the door, on the floor, in the dark on a train and in the rain. (This is starting to sound like a Dr. Seuss book, but it really is true.) We should make our first attempt our best attempt, so we should try to pick a place or modify the conditions to create our best attempt. If we can get the patient to the stretcher and an elevation and position that enhances our ability to obtain direct visualization of the airway, we’re setting ourselves up for success.

One bad habit I see providers have in the field is to slide the patient to the end of the cot and allow their head to hang back or attempting to intubate with the cervical collar in place. Again, think about the anatomy, have you ever tried to talk with a cervical collar on or hang your head over the back of the chair you’re sitting in? Did you notice that your chin was pointing one direction and your airway was going the other? Provide the patient has no cervical injury the ideal position would be to lift the patients head so to bring their ears even with their chest, you may hear this referred to as ear-to-sternal notch or a wedge technique.

Another great trick you might want to think about is a concept that Dr. Richard Levitan introduced in his book, “The Airway Cam Guide to Intubation and Practical Emergency Airway Management”, ELM or bimanual laryngoscopy, where the intubator actually will manipulate the trachea to bring the glottis opening into view. If the patient has a suspected cervical spine injury, hold inline stabilization while another provider secures the airway, allowing the jaw to be manipulated without restriction. We can’t always relocate the patient when we need to control the airway, so try to use gravity and the patient’s own anatomy to assist in locating and securing the airway.

Why & How
That would leave us with two final questions: why and how. The “why” is pretty simple, to oxygenate my patient. However, that is easier said than done because many of the airway adjuncts we use and the oxygen delivery system are subject to human error, failure or misuse result in injury to the patient, hyper- or hypo-oxygenation, so we must constantly reassess to ensure we are providing adequate oxygenation in a safe manner.

Finally comes the “how?” The simple answer is to do things with the easiest, safest and most efficient means possible. Every situation is different; some patients may require a simple oropharyngeal airway (OPA), a few breaths and transport. Another may need RSI, a definitive airway and the use of video laryngoscopy, which uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. A few may even need a surgical airway.

What benefit might video laryngoscope have that traditional direct laryngoscope does not?

View Results

Loading ... Loading ...

Conclusion
The patient, the situation, the patient’s illness or injury, the provider’s experience, and the resources available will determine the tools and means of airway control. Ultimately you have to have an airway plan tattooed on your brain so it’s right there every time you need to manage an airway. We’ll save that discussion for another day.

I hope the next time you pick up a laryngoscope or an endotracheal tube you ask yourself these simple questions: who, what, where, when, why and how. Hope to see you soon.

Stay safe,
Jim Radcliffe, BS, MBA, EMT-P

Post to Twitter

Video Laryngoscopy’s Place in an Ambulance

Tags: , , , , , , , , , , , ,


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.

Post to Twitter

Airway Algorithms

Tags: , , , , , , , , ,


Airway Management AlgorithmIn my last EMS Airway Clinic article, “How to Make the Difficult Airway Less Difficult,” we looked at situations that can make airway management difficult; one of those situations was not having a strategy. Today, I’ll share with you the airway algorithm that has helped me over the years, and I want to give you some tips for building your own algorithm.

As professionals, we should know our protocols. We should be able to deliver quality patient care without looking up the details. I believe these ambitions, but folks, I’m just not one of those medics who remembers every nook and cranny of the protocol book. My worst example is the Glasgow Coma Scale. What a great tool to objectively record the conscious state of a patient. Let’s see, I know that if I’m dead for two weeks, I get a three, and I’m a 13 or a 14 when I get up in the morning. Otherwise, I’ve got to either look it up or use a memory aid, such as an algorithm.

An algorithm is “a step by step procedure for solving a problem.”(1) Medical algorithms help us deliver better patient care. They standardize treatment therapies, so we collectively deliver similar care in similar situations. They help us successfully navigate low-incidence, high-consequence incidents. They reduce medical errors. In EMS, we typically use two types of algorithms: flowcharts and checklists.

Flow charts guide us through a series of “if-then” situations that help us respond quickly and effectively in critical situations; if the patient is in ventricular fibrillation, then defibrillate them. A checklist is a memory aid to make sure we don’t forget something, especially in a situation that we don’t face regularly. A checklist for rapid sequence intubation (RSI) helps us remember to check patients for all contraindications.

I’ve found several characteristics that are commonly found in good emergency airway management algorithms. First and foremost, the algorithm must be based on your world—your patient population, distance to hospitals, available equipment and staff, as well as your own training, experience and confidence. It’s convenient to borrow an algorithm, but it won’t work if it doesn’t fit your operational environment. Using a hospital-based airway algorithm just doesn’t work in the parking lot of the Piggly Wiggly. A second feature of a good algorithm is comfort. If it’s awkward and unfamiliar, then you won’t use it well if at all. You make it comfortable by practicing and making adjustments. Finally, a good algorithm has to be systematic. It must logically and easily flow from one step to the next.

My Algorithm
I’ve used my current airway algorithm for about 15 years. Now, I didn’t just sit down at the kitchen table one morning and put it on paper. I started out using someone else’s algorithm, and then I gradually changed it to fit my needs. My algorithm will always be a work in progress. When I started, I didn’t consider video laryngoscopy or a bougie. Now, they both sit in a place of prominence.

Every patient receives oxygen at every possible moment. Do everything you can to wash out all of the nitrogen in the patient’s lungs and replace it with oxygen. A hyper-oxygenated patient will tolerate short periods of apnea better than a patient with low oxygenation.

Every EMS provider must be proficient at bag-valve-mask (BVM) ventilation. I think BVM ventilation is so important that it’s mentioned six times in my algorithm. I start with BVM to get a feel for compliance and how well the patient responds. Some folks do quite well with a little oxygen, an oral airway and gentle BVM ventilation. If my attempts at laryngoscopy or an alternative airway are unsuccessful, I reach right for the BVM.

Should we intubate?

View Results

Loading ... Loading ...

I’ve found that more than two attempts at laryngoscopy is usually a waste of a patient’s precious time because chances of success decrease with each attempt. I prepare to successfully place an endotracheal tube on my first attempt. I do everything to make my first attempt my best attempt. I have a second laryngoscopy attempt in the algorithm as an opportunity to make a course correction if I encounter an unanticipated condition, a technique or equipment failure, or I fail to prepare well enough.

I used to have supra-glottic airway placement as steps five and six in the algorithm until a colleague pointed out his success with nasal-tracheal intubation and digital intubation. Out of respect for Steve, I’ve changed these steps to use of an alternative airway. Similar to my experiences with multiple attempts at laryngoscopy, I’ve found that more than two attempts with an alternative airway become futile and detrimental to the patient. If you displace the tongue sufficiently and use adequate lubricant, first-pass success is likely. I’ve included a second attempt in the algorithm to give myself the opportunity to address an unexpected condition or a misstep in my preparation.

Step seven is our familiar friend, BVM ventilation and a quick ride to the hospital.

How long should you spend on each intubation attempt? Wow, that’s a loaded question. I wish I could give you a solid number backed up with a stack of studies, but I can’t. The time spent depends on the patient’s physiological condition, the level of difficulty you experience and your skill level. Many of us were taught to spend no more than 30seconds on an intubation attempt, and I think that’s a pretty safe number. From the moment you insert the blade into the patient’s mouth, it should take you about 10 seconds to locate the glottic structures, and then no more than another 10 seconds or so to place the tube, inflate the cuff and withdraw the stylette. The remaining 10 seconds are a pad for handling any surprises you might find.

I’d like to hear your thoughts on this. How much time do you think we should spend securing an airway?

Your Turn
Feel free to use this algorithm as template from which you build your own. A word of caution; an algorithm is one tool. It isn’t a replacement for sound clinical judgment. Please let me know how you fare in creating your own airway algorithm. In my next EMS Airway Clinic article, I’ll talk about some of the things you can do to improve your first pass success rate.

Be safe my friends.
Charlie

References
1. Merriam-Webster. www.m-m.com/dictionary/algorithm.

Post to Twitter

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.

More Posts

An Introduction to Video Laryngoscopy

Tags: , , , , , ,


The GlideScope Ranger in use by Dr. David Cannell, during a medical mission in the Philippines. Photo Verathon

“…video laryngoscope provided excellent laryngeal exposure in a patient whom multiple experienced anesthesiologists had repeatedly found to be difficult or impossible to intubate using direct laryngoscopy.”(1)

Let me put my view of video laryngoscopy right up front. Video laryngoscopy is better than direct laryngoscopy. It reliably provides a better view and requires less force than direct laryngoscopy. There’s less trauma to the patient. First-pass intubation success rates are higher and require less time than direct laryngoscopy. Video laryngoscopy is better for our patients and should be the standard of care for oral tracheal intubation.

Wow, Charlie, those are pretty bold statements! I make these statements based on five years of experience with a variety of video laryngoscopes in the field, the operating room (OR) and cadaver labs. I have these views based on the scores of journal articles and studies I’ve reviewed. I have these beliefs from conversations EMS, anesthesia and emergency medicine professionals from the U.S., Canada, Europe, Australia and Asia. Ask anyone who has ever used a video laryngoscope and you’ll find very few who don’t agree with most of my statements. Yep, I’m pretty comfortable with my point of view, but this wasn’t always my position.

I’m a tightwad. Just ask my wife and anyone I’ve worked with. I hate spending money, especially my own. Also, I am a skeptic. I look at new technology with a suspicious eye. I see no reason to change for the sake of change. Imagine my thoughts back in 2006 when I first saw a video laryngoscope. Wow! That’s a lot of money for a camera and some lights. I’ve done just fine intubating patients for over twenty years with my metal sticks, why should I change? It took me at least a year of working with the instrument before I started to believe there was a better way to intubate my patients.

Direct laryngoscopy has changed very little since its implementation in medicine over a century ago. The early ’90s saw several developments in the anesthesia world. In operating rooms, flexible and rigid fiber optic devices were used to place endotracheal tubes in patients with difficult airways. Even seasoned professionals needed extensive practice with these devices.(2) It was incredibly rare for these instruments to find their way to an emergency department, let alone in the hands of EMS providers.

I’d like to tell you that anesthesiologists used fiber optic instruments as the springboard to video laryngoscopy, but I can’t do that. Video laryngoscopy truly had its birth in the profession of surgery; specifically laparoscopic surgery. The earliest patent I could find for a video laryngoscope was issued to Dr. Jonathan Berall in 1998.(3) The first commercially available video laryngoscope was designed by Canadian surgeon, Dr. John Allen Pacey and introduced in 2001.

I have to make a disclosure here. Dr. Pacey is one of my EMS heroes. He’s a soft-spoken man, but vigorously passionate in caring for his patients and developing new technologies. I’ve known Dr. Pacey for years and I’m honored and humbled to call him my friend. Earlier this year, I was privileged to interview him for this website. During the interview, he told the story of how he developed the GlideScope. I’ve heard the story countless times, but each time it’s told, I listen with wonder. Watch the video interview and see what I mean.
It took me a while to understand that video laryngoscopes are not traditional laryngoscopes. I was routinely frustrated and typically unsuccessful because I tried to apply direct laryngoscopy skills. My epiphany came when I finally realized it isn’t a laryngoscope, it’s a camera! With that paradigm shift, I became proficient. It’s the function of every video laryngoscope to place a miniature camera and light in the supraglottic region and transmit the image to a monitor.

A number of instruments are on the market, and they differ in the location of the viewing monitor, shape of the blade and method of inserting the endotracheal tube. Monitors are either attached directly to the laryngoscope handle or at the end of a cable that is connected to the handle. Attached monitors are compact and typically take up less room in gear bags. When you adjust the handle with an attached monitor, you also have to move your head to stay in front of the screen. Detached monitors provide a larger viewing screen and don’t require you to move your head when you adjust the handle.

I’ve seen three blade shapes; a modified Macintosh, an L shape and the proprietary angle of the GlideScope. Remember, the blade is the vehicle used to place the camera and lights in the supraglottic area using the least amount of force. I’ve found the greatest success by using my thumb and two fingers to manipulate the blade; it just doesn’t take much pressure to obtain a view. If you have to apply significant force to obtain a video view, you need to perfect your technique or try different shaped blade.

Two of the L shaped instruments I’ve used with monitors attached to the handles have an endotracheal tube channel on the right side of the blade. Once you have a clear view of the glottis, advance the tube through the channel into the glottis. The other method of placing a tube is manually placing the tube with your right hand. Some of my European friends prefer to place the tube without a stylette, but I’ve had much greater success using one.

Each device offers other features such as video and still recordings, disposable or reusable blades, battery type, air worthiness certificates, ruggedness, size and monitor size. The best way to determine which video laryngoscope is best for you is to put one in your hand. Try as many as possible. Start with manikins, and then move to the cadaver lab and patients. I’ve used pretty much everyone out there, so let me know if you have any questions.

Let’s talk about the elephant in the room; cost. I’ve met very few folks who weren’t impressed with the view, ease of use, and superiority of video laryngoscopes over direct laryngoscopy. I’ve met very few folks who didn’t hesitate when they saw the price tags and I was one of them. While I am still a card carrying tightwad, I do believe you get what you pay for.

How many of you old timers remember using a Porta-Power and Come-Along for vehicle extrication? When Ed Curtrell showed us a new fangled hydraulic tool, a Model 32 spreader, he wanted $5,000 for the system. Show me a rescue unit today without a high pressure hydraulic tool; it’s the industry standard. Last year, the State of Maryland required every ALS unit to have cardiac monitors with 12-lead ECG capabilities. How much did you pay for your most recent monitor? It’s the standard of care.

With all of the recent literature, articles, and editorials questioning EMS providers’ competency to provide endotracheal intubation, I just don’t understand why folks aren’t running to this proven technology. End-tidal carbon dioxide capnography isn’t cheap, but we embraced it and made it a standard of care. Because of adverse court settlements involving direct laryngoscopy, the attorney for a community based emergency physicians group proactively recommended the group drop direct laryngoscopy by its emergency physicians. The group now either intubates in the emergency department via video laryngoscopy or places a supraglottic airway.

The two operational medical directors who have had the greatest impact on my EMS career are Frank M. Yeiser, Jr., MD and Douglas Floccare, MD. Both of these men taught me that same thing; just do what’s best for your patient. Friends, video laryngoscopy is what’s best for your patients.

Take care and be safe.
Charlie

References
1. Richard M. Cooper, Can J Anesth. 2003;50:6, 611-613.
2. Clifford Boehm, MD Assistant Professor of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Personal communication, 2008.
3. Jonathan Berall, US Patent 5,827,178, www.uspto.gov.

Post to Twitter

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.

More Posts

The Video Laryngoscopy Movement

Tags: , , , , , , , ,


By John Allen Pacey, MD, FRCSc

In 1829, the first known device for direct laryngoscopy was invented by British physician Benjamin Guy Babington. Later, the work of the widely recognized father of laryngology, Manuel Garcia, led to the first mirror laryngoscope prior to 1849, with a light source later introduced by Alfred Kirstein in 1895.(1)

In the century since then, the devices available to view the larynx have gone through many evolutions. Most devices have been difficult to use, and injuries related to failed or delayed tracheal intubation have resulted. Recognizing that optimal airway management involves the direct visualization of the airway during intubation, modern direct laryngoscopy has produced different blade lengths, prisms and fiber-optic light channels. However, the emergence of video capabilities in the surgical suite was perhaps the most significant step in laryngoscopy development.

Video laryngoscopy systems provide a clear picture of the larynx and vocal cords on a display monitor, enabling control of the endotracheal tube (ETT) in its trajectory toward the airway. This type of clearly displayed view facilitates fast, accurate ETT placement in difficult airways, preventing complications resulting from improper tube placement.

Other advantages of video laryngoscopy compared with older, fiber-optic systems are substantial. Video images are easily stored on servers and low-cost SD cards, and can be transmitted to other users, allowing for remote recording of activity, skills coaching and quality assurance reviews. The use of Internet display is easy either with real-time transmission or by display of the captured images, so that the captured sequences can be used for teaching purposes to improve the skills of many. As HDTV technology improves, so will the image quality of video laryngoscopy. Last, video laryngoscopic techniques are easier to master than those necessary for direct laryngoscopy, an important factor in its successful use by personnel working in less-than-optimal circumstances.

Initial advocates of video laryngoscopy were anesthesiologists in Vancouver, Canada, who performed intubations daily. Such luminaries as Richard Cooper, BSc, MSc, MD, FRCPC; John Doyle, MD, PhD; and Ron Walls, MD, raised questions about the viability of direct laryngoscopy compared with video laryngoscopy and sponsored the adoption of the technology in other areas of the hospital, such as the emergency department (ED) and the ICU. While recognizing the expense of adding the video component, Cooper in particular has commented that video laryngoscopes are “more robust and resistant to damage.”(2) Adoption in EDs and ICUs has been rapid, and it seemed only a matter of time until video laryngoscopy was introduced into prehospital medicine.

The Need in the Field
The literature shows that intubation performed in an out-of-hospital emergency environment carries with it a higher rate of complications and death.(3) Rapid sequence intubation (RSI), called for by Rosen and others, initially appeared to be effective when coupled with direct laryngoscopy (97% in some reports).(4) But optimism dissipated when a 2003 San Diego study reported that 45% of “easy” or successful intubations carried out on head-injured patients were associated with hypoxemia or bradycardia.(5)

In pediatric patients, the literature shows a need for improved methods. A 2000 San Diego study of 305 pediatric patients showed a success rate of 57%, esophageal intubation of 2% and displaced ETT of 15%.6 An older study, from 1989, reported a 50% success rate in children one year in age or younger.(7)

The reasons for these failure rates are obvious to anyone who has worked in the field: the variable intubation skill levels among EMS personnel and adverse conditions, such as weather, limited lighting, foreign bodies in the airway and trauma (leading to hemorrhage and distorted anatomy). Because direct laryngoscopy in these conditions continues to be fraught with difficulty, EMS medical directors are reconsidering their airway management protocols. Although it’s clear some EMS personnel are able to overcome the deficiencies of direct laryngoscopy and produce acceptable results, the failure rates have provoked questions of whether direct laryngoscopy has become a “legacy technique,” introduced when there were no alternatives.(8)

GlideScope in Use
In 2001, the GlideScope® was introduced as the first commercially available video laryngoscope. The device was designed with the recognition that a camera positioned away from the tip of the device would provide the best perspective and enhance visualization. The 60º angle allows for 99% Grade 1 and 2 views.2 Another significant design feature is the device’s unique anti-fog component, which reduces lens contamination.

The GlideScope Ranger single-use laryngoscope—designed to eliminate the need for disinfecting the blade for fast-paced intubation settings—is being used in Iraq and Afghanistan. The backpack-sized, rugged and shockproof version of the original device with an antiglare screen was trialed at the R. Adams Cowley Shock Trauma Center, Fort Sam Houston and Andrews Air Force Base. Following successful trials of the device at these world-renowned medical facilities, the Ranger was deployed in hospitals and combat settings.

In particular, a number of reports from the Canadian Expeditionary Hospital in Kandahar, Afghanistan, involve the management of bloody airways, intubation around expanding hematomas and other challenging ETT exchanges. The Ranger is also in trials with Whatcom County (Wash.) EMS, where the early results are encouraging, according to Medical Director Marvin Wayne, MD.

Aeromedical applications, notably in helicopter environments, are also under study with the GlideScope Ranger. It’s notable that first-time aeromedical users had a high success rate even in the most adverse conditions. Reports of Ranger intubation under unusual conditions include two intubations prior to extrication from crushed vehicles, in flight re-intubation, and in-flight primary intubation (where direct laryngoscope use is limited).

A Look Forward
There’s considerable pressure on EMS to improve successful intubation rates, and the advent of video laryngoscopy designed for the field is poised to produce findings that support its use in this demanding context. How extensive a role this technology will play is complicated by the debate over whether intubation—considered the gold standard in anesthesia practice—is necessary for all compromised airways. EMS personnel work with patients who are often treated under adverse conditions, and there will always be a need for difficult airway management in the trauma setting. A growing amount of evidence supports the view that video laryngoscopy will be a standard in that setting, but more studies are needed before it’s an established reality.

As for speculation about the future of video laryngoscopy in the prehospital setting, aeromedical studies will likely continue to demonstrate the efficacy of RSI using video laryngoscopy. It’s felt that “time on the ground” can be significantly reduced by the use of video laryngoscopy-assisted RSI, either pre-flight or in-flight. Also, many feel RSI coupled with video laryngoscopy will be shown as the most effective strategy for prehospital intubation management, which will likely involve development of supraglottic airway technology.

The cost of failed or difficult intubation can be very high as reflected in a private settlement in excess of $15 million in 2002.(9) There’s also the cost associated with emotional burden to the providers involved, who may face insurmountable obstacles to care.

The added value of video recording will allow medical directors to more accurately measure personnel competency and skill success rates, document the depth of ETT insertion and enhance education. Overall, these devices can aid emergency airway management and likely lead to better patient care—a universal goal of all EMS providers.

References
1. Proceedings of the Royal Society of London. vii:399–410, 1856.
2. Cooper RM, Pacey JA, Bishop MJ, et al: “Early clinical experience with a new video laryngoscope (GlideScope) in 728 patients.” Canadian Journal of Anaesthesia. 52(2):191–198, 2005.
3. Murray JA, Demetriades D, Berne TV, et al: “Prehospital intubation in patients with severe head injury.” Journal of Trauma. 49(6):1065–1070.
4. Bulger EM, Copass MK, Maier RV, et al: “An analysis of advanced prehospital airway management.” Journal of Emergency Medicine. 23(2):183–189, 2002.
5. Dunford JV, Davis DP, Ochs M, et al: “Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation.” Annals of Emergency Medicine. 42(6):721–728, 2003.
6. Gausche M, Lewis RJ, Stratton SJ, et al: “Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial.” JAMA. 283(6):783–790, 2000.
7. Aijian P, Tsai A, Knopp R, et al: “Endotracheal intubation of pediatric patients by paramedics.” Annals of Emergency Medicine. 18(5):489–494, 1989.
8. Cooper RM: “Is direct laryngoscopy obsolete?” Internet Journal of Airway Manage­ment. Vol. 4, 2006–2007. www.adair.at/ijam/volume04/specialcomment01/default.htm
9. Law Offices of Wade E. Byrd, P.A. 232 Person St. Fayetteville, NC 28301.

Disclosure: The author is the inventor of the GlideScope, and president and research director for Verathon Medical Canada, the makers of GlideScope systems.

This article originally appeared in The Perfect View.

Post to Twitter

Welcome to EMS Airway Clinic!

Tags: , , , , , ,


Should we intubate?

View Results

Loading ... Loading ...

Welcome to the first edition of the “EMS Airway Clinic.” I’m Charlie Eisele, your host, guide and pathfinder through the world of prehospital airway medicine. We created this site to do one thing: provide patients with the best care possible. We’ll do just that by targeting the folks who directly impact patient care: educators, medical directors, and street level, mud on your boots, stretcher carrying EMS providers. It doesn’t matter your level of training or how many letters you have after your name, you will leave this site with stuff you can put to use immediately.

When the title came across my desk, I just had to ask, “What the heck is an airway clinic?” Prince.edu gave me a couple of answers:

  1. A medical establishment run by a group of medical specialists;
  2. A meeting for diagnosis of problems and instruction or remedial work in a particular activity;
  3. A health-care facility for outpatient care; and
  4. A musical clinic is an informal meeting with a guest musician, where a small-to-medium sized audience questions the musician’s styles and techniques and also how to improve their own skill.

I immediately threw out the first and third. Number two has merit, but I really like number four. EMS Airway Clinic is an informal meeting with guests to provide a variety of styles and techniques to improve our skills.

Are you allowed to intubate?

View Results

Loading ... Loading ...

Here you’ll see articles, videos, podcasts and a variety of other vehicles to share best practices in airway management. I really like case studies. They’re a great way to gain experience without having to make mistakes yourself. Sometimes, you just want to know how something works, so there will be “how to” items. We will provide timely news stories that impact EMS airway management and previously published articles to download, and we’ll keep you up-to-date on relevant studies and journal articles.

Here’s a preview of upcoming topics:

  • The Glottis Is Not Your Friend
  • Quotes from My Airway Heroes
  • Video Interview with Dr. Jack Pacey
  • Roadmap to the Larynx
  • Sun Tzu: The Art of Airway Management

My vision is that this site be reader driven, so tell me what you want. What topics interest you? What tools and techniques have you found successful? I know you’ve got case studies and war stories; let’s hear them.

I’m a huge fan of professional, open discussions, so expect me to weigh in on controversial topics. Say, something like “should we intubate?”

Related Link

Post to Twitter

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.

More Posts


EMS Airway Clinic is a new site offering best practices in airway management and education for EMS professionals and educators, featuring:
  • • Regular articles by Charlie Eisele, Flight Paramedic, retired First Sergeant with the Maryland State Police Aviation Command, and co-founder of the Advanced Airway Course at EMS Today
  • • Case studies, how-to videos and podcasts
  • • The "Airway Funnies" from popular EMS cartoonist Steve Berry
  • • The latest news, features and educational content on prehospital airway management
  • Learn more about EMS Airway Clinic

    Like Us on Facebook

    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.

    See more products …

    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.

    See more products …

    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.

    See more products …

    Featuring Recent Posts WordPress Widget development by YD