airway and tonopens...

[whasupmd2]

If you had the ability to ask for any backup airway equipment, what would you ask for (in order of preference)?

Also, what tonopens are you all using? All the ones that i've seen are not reliable, give variable readings and break. Has anyone had good experience with the ones you have used? What brand/model is it?

Thanks!

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[step1]

I agree that tonopens are unreliable, esp when first using them.

I noticed that Ophtho's tend to get pretty good reads from them. They do it all the time and are experienced with the tonopen.

But if you're using for the first few times, it's hard to get something accurate (ie, pressing too hard or light, going off the side of the cornea and not being at a straight 180 deg angle) - I'm no ophtho expert so i can't give specifics on techniques.

I think it takes a bit of practice.

 

[GeneralVeers]

We had a brand new tonopen at King that worked extremely well, and gave reliable readings for the residents. Unfortunately it ran out of batteries, and in typical L.A. County fashion, there was no way to re-order any more.

 

[edinOH]

We had a brand new tonopen at King that worked extremely well, and gave reliable readings for the residents. Unfortunately it ran out of batteries, and in typical L.A. County fashion, there was no way to re-order any more.

I ran into this once in residency. A quick trip to Radio Shack solved the problem.

I love the tonopen. I used it extensively as a tech prior to medical school so I feel like I get reliable readings.

As far as back up equipment goes:

1) Bougie (sp?)
2) fiber optic laryngoscope
3) LMA
4) #11 blade

 

[2ndyear]

Airway backups, after you've called for help, tried a different blade, etc.:
1) LMA, gotta ventilate, buy some time and find some equipment.
2) Intubating LMA. Easy to use blind technique. Don't need much training on this one at all. Can combine it with a fiberoptic scope while maintaining ventilation if you so desire.
3) Bougie. Pretty simple, takes some skill though.
4) Bullard. This one solves some of the problems that might have made intubation difficult in the first place. Minimal mouth opening required. No neck extension is required, easy to use in a c-collar. It takes some learning in a controlled environment, and fails where other direct vision techniques fail: the grossly contaminated airway by active bleeding/secretions/vomit.
5) A 14 ga Angiocath, central line kit, McGill forceps and a prayer.

 

[kungfufishing]

4) #11 blade

dang man is that a mac or miller? huge. just sort of plows its' own course into the mediastinum, I see you working.

A joke.

1.frova bougie (can ventilate through it)
2.intubating LMA
3.scope
4.#11



No idea what kind of tonopen we have but it hasnt had issues in all my months.

 

[DropkickMurphy]

This is the pattern I've become most familiar with using and/or assisting with (in the case of retrogrades):
-Standard approach (I prefer Mac blades)
-Bougie
-LMA (or a Combitube, since we unfortunately can't use LMAs prehospitally here)
-Crike or retrograde

 

[bartleby]

With the tonopen, I have come up with a couple of strategies to help get better and more consistent numbers:

1. Thorough anesthesia. If they blink or jerk away when you poke them in the eyeball, you're not going to get a good read. You should put tetracaine or another topical drop of your choice in until they have no discomfort with touching their cornea. This will often take 3-4 rounds of drop application 30 secs apart

2. Proper positioning of the tonopen condom. No bunches between the sensor and the eyeball. I'm sure you remember from high school... "pinch the tip and roll down to the base of the shaft..."

3. The tonopen should be held perpendicular to the cornea. No glancing blows.

4. Measure with a gentle tapping motion.

5. If they're still blinking, pin their lids back to the bony rim of the eye socket with your fingers or use an eyelid speculum (available commercially or fashioned from two unbent paper clips cleaned throughly with alcohol) if there is lid edema. But if there is massive trauma and you suspect a ruptured globe, you shouldn't be doing any of this anyway.

 

[VA Hopeful Dr]

With the tonopen, I have come up with a couple of strategies to help get better and more consistent numbers:

1. Thorough anesthesia. If they blink or jerk away when you poke them in the eyeball, you're not going to get a good read. You should put tetracaine or another topical drop of your choice in until they have no discomfort with touching their cornea. This will often take 3-4 rounds of drop application 30 secs apart

Get a better anesthetic drop. I've found that one good drop of proparacaine will do the job just fine. Plus, wears off in about 15 minutes.

2. Proper positioning of the tonopen condom. No bunches between the sensor and the eyeball. I'm sure you remember from high school... "pinch the tip and roll down to the base of the shaft..."

Oddly enough that was exactly how I was taught to do the tonopen cover "just like a condom". Made slightly surreal since a 50 year old 300lbs nurse told me this.

3. The tonopen should be held perpendicular to the cornea. No glancing blows.

I've found that if you rest part of your palm against the person's face below the eye, you can get a good angle that way.

4. Measure with a gentle tapping motion.

Agreed.

5. If they're still blinking, pin their lids back to the bony rim of the eye socket with your fingers or use an eyelid speculum (available commercially or fashioned from two unbent paper clips cleaned throughly with alcohol) if there is lid edema. But if there is massive trauma and you suspect a ruptured globe, you shouldn't be doing any of this anyway.

Good call. Even on healthy folks, you need to be careful of how you handle their lids. Needs to be done in such a way so no extra pressure is put on the globe itself. You way is exactly what I do.

For best accuracy, I prefer NCT.... but tonopen is great for its portability.