Airway Question...

[FoughtFyr]

Here is a thought - why do we use laryngoscopes? I'm being serious. Why not do every tube in the ED via fiberoptic scope. Here is my thinking - almost every M&M I have been to in EM has a case that goes something like "we assessed the need to intubate the patient and decided to perform RSI. Thyromental distance was good, Mallampati score and Cormack grade gave us no cause for concern. However, once intubation was attempted, it was difficult to visualize the cords. Three attempts were made with ventilation via BVM between each attempt. Intubation was finally achieved via gumbogie stick".

Now, I realize that fiberoptic is difficult to set up as a "crash" backup when things are going to $hit, but why not start with it. The failure rates of fiberoptic intubation are extremely low (orders of magnitude below laryngoscopy), if the unit is setup as the primary intubation tool there are no additional costs in time or risks to the patient, so why not acknowledge the emergent nature of intubation in the ED and start with the best tool for the job?

Just a thought...

- H

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[spyderdoc]

Here is a thought - why do we use laryngoscopes? I'm being serious. Why not do every tube in the ED via fiberoptic scope. Here is my thinking - almost every M&M I have been to in EM has a case that goes something like "we assessed the need to intubate the patient and decided to perform RSI. Thyromental distance was good, Mallampati score and Cormack grade gave us no cause for concern. However, once intubation was attempted, it was difficult to visualize the cords. Three attempts were made with ventilation via BVM between each attempt. Intubation was finally achieved via gumbogie stick".

Now, I realize that fiberoptic is difficult to set up as a "crash" backup when things are going to $hit, but why not start with it. The failure rates of fiberoptic intubation are extremely low (orders of magnitude below laryngoscopy), if the unit is setup as the primary intubation tool there are no additional costs in time or risks to the patient, so why not acknowledge the emergent nature of intubation in the ED and start with the best tool for the job?

Just a thought...

- H

Yes, but the success rate of laryngoscopic intubations is very high, over 95+%...Why change a practice that has a very high success rate to begin with....Fiberoptic scope is a good backup device, but expensive. We do not have one in our ED, and I've never actually done one, except on a goat during advanced airway lab....

 

[FoughtFyr]

Yes, but the success rate of laryngoscopic intubations is very high, over 95+%...Why change a practice that has a very high success rate to begin with....Fiberoptic scope is a good backup device, but expensive. We do not have one in our ED, and I've never actually done one, except on a goat during advanced airway lab....

But that's the thing, is it a backup device? No one is good with it, it is not in routine use outside of the OR, and most ED staff don't know how to set it up.

I agree with you that the laryngoscopic success rate is very high, but what percentage of EM poor outcomes relate back to airway difficulty? If the NNT is 33 (or so) isn't it worth it on something as critical as an airway? I guess I look at the rest of our practice and the adaptations we made in the name of "preparing for the worst" and wonder why we do not look to increase our airway success rate (even if only by a small measure).

- H

 

[roja]

I've watched several of these in the OR. These are *incredibly* difficult. We don't even have them in our ED. (waaaaaaaaaaaaaay to expensive) I wouldn't consider in my 'back up' plan.

 

[spyderdoc]

But that's the thing, is it a backup device? No one is good with it, it is not in routine use outside of the OR, and most ED staff don't know how to set it up.

I agree with you that the laryngoscopic success rate is very high, but what percentage of EM poor outcomes relate back to airway difficulty? If the NNT is 33 (or so) isn't it worth it on something as critical as an airway? I guess I look at the rest of our practice and the adaptations we made in the name of "preparing for the worst" and wonder why we do not look to increase our airway success rate (even if only by a small measure).

- H

I call for backup (either a colleague or anesthesia) early on if I have immediate problems visualizing cords. Of the 1 or 2 pts that I had probs with in my 2 1/2 yrs out of residency, either a colleague or anesthesia was able to get it....In case they can't, we have a lighted stylet, a retrograde kit, and if all else fails, a crich kit available in our difficult airway box.....

Also, one would think that there would tend to be a lot of airway complications in residency programs in general. The patient probably had the whole chain of command from intern to attending attempt to get the airway, and surely someone along the way lacerates something, or causes some sort of problems....At our M+M's, in a community hosp in inner city, we do plenty of intubations, and very rarely do we get any complications strictly from inserting airways.....Probably less complications because of the experience of the providers.....Something to consider....

 

[pratik7]

not only are they expensive and difficult to use as stated above; they are a pain to clean and sterilize. They take a couple of hours and therefore you would need to buy several scopes making it even less realistic. ahh memories of my days as an anesthesia tech

 

[Febrifuge]

Man, I can't tell you how many times I've struggled to hang the goopy end of the scope down into the fluid bath, leaving the optics and electronics on the edge of the little tub... we have three or four fiber-optic scopes, and the problem is the light source. It's always sort of close to the last place it was used. I think our residents just Bougie everything as a matter of course.

 

[Doczilla]

Related question- anyone out there keep a commercial cric kit like the NuTrach or PeriTrach or Melker on the airway cart? Or do you just do it with the scalpel?


'zilla

 

[roja]

I'm going to go out on a limb. We don't have a bougie... I have heard wonderful things about this. We basically have to get the airway or well.....

We have only had one crich and it was done secondary to angioedema. We don't have a preset kit.

I do always carry a scalpel and a 14 gauge needle. Don't ever really want to have to say, um, can someone get me a scalpel please?????????/

 

[docB]

I can't say enough good things about bougies. A bougie bailed me out of a nasty situation just yesterday. I always prefer low tech to high tech.

 

[trauma_junky]

LMA's are great for failed airways. There is some new thing on the market called the glide scope. I saw it at a show last year and it was cool. There are tons of prehospital classes that teach crash airway techniques. SLAM (street level airway managment) is one of my favorites.

There are two extra things I always have ready when I intubate: 1 mg of atropine and a scaple.

 

[spyderdoc]

Related question- anyone out there keep a commercial cric kit like the NuTrach or PeriTrach or Melker on the airway cart? Or do you just do it with the scalpel?


'zilla

We do have a crich kit in our difficult airway box, but the three crichs (all during residency) that I've done, I used a 15 blade and a #6 ETT and it worked beautifully. Had the airway in about 30sec on each one....I think it would probably take longer to use the kit just due to the "fumbling around" factor involved in opening the kit and sorting through the equipment...

 

[Andy Kahn]

i am the intern on the trauma service right now, but i went in on a medical pt who ended up in one of the trauma booths yesterday. Pt had some congenital syndrome with a small troll like body and craniosyntosis (48 yo M h/o IVDA, DM, CHF, Prot C def... He needed to be tubed so I brought in our "difficult airway bag." The 3rd year tried to look with the DL and then asked for the bougie. It was great. I used the bougie in a cadaver recently and it seemed great (and i also did manual/digital intubation with the cadaver). Here's my algorithm for difficult airway that I have in my head so far (but i'm still just an intern with time to learn and adapt)...

1. DL (mac or miller)
2. DL (trying the other blade, w/ better cricoid or head positioning, jaw thrust, etc.)
3. bougie
4. digital intubation (and putting something in the mouth to avoid getting bitten).
5. cric (using any scalpel near by to cut the skin vertically, then poking into the cricothyroid membrane, sliding a hemostat or something else that is firm enough to keep the opening from being lost, but not a finger that could get cut by the blade... I guess I would use a smaller ETT and I would cut the end of the ETT and put the cap back on the remaining end of the ETT so it isn't so long and has less of a chance to be dislodged. The ETT could be replaced by a Shiley later by Seldinger technique using the wire from a central line kit.)

I don't see the use of a retrograde (except only needle available or attempting to leave smaller scar, but by that desperate point, you may want to cric to secure airway)

-andy

 

[bartleby]

Here is a thought - why do we use laryngoscopes? - H

Good points by other posters so far, but a couple of other quick points come to mind. First, one of the big downside of the fiberoptic scope is that you need to do it many times, preferable on a simulator, till you're comfortable enough with the "knobology" of it to make a safe attempt on a living patient. But remember that people aren't dry like a mannikin up there when you have CHF froth, saliva, and blood from 3+ previous direct laryngoscopy attempts. I have found that scoping through a FastTrach (intubating LMA) is quite a bit easier as you a) can bag the patient up to buy to a bit of time for your attempt with the scope and b) have a stable conduit through the pharynx to the neighborhood of the cords.

One note about digital intubation... it should not be done on a patient who is not being RSI'ed or not comatose minus a gag reflex. You don't want to get bitten or have a get injured, nor do you want to stimulate a gag when you reach down there. Having said that, it's a good trick to remember on a rainy day, and you always have the necessary equipment with you.

 

[FoughtFyr]

One note about digital intubation... it should not be done on a patient who is not being RSI'ed or not comatose minus a gag reflex. You don't want to get bitten or have a get injured, nor do you want to stimulate a gag when you reach down there. Having said that, it's a good trick to remember on a rainy day, and you always have the necessary equipment with you.

Having done 12-15 as a 'medic, I am a HUGE fan of digital intubation - especially when the pt. is in c-spine precautions. I have used it as my first method of choice if I strongly suspected an actual spine injury.

- H

 

[The White Coat Investor]

We have a glide scope...it's sweet, but expensive and won't be available most likely wherever I go. I don't recall ever seeing an airway M&M, but I do remember one case that went bad. Of course, the little girl had severed her right bronchus from her trachea, and split her trachea from cords to carina. Having the tube through the cords didn't do much good.

I carry my cric kit in my pocket....a # 10 blade and a cric hook. After that it's just insert the ETT until you get a chance to change it out for a shiley. The hard part about a crich isn't doing the procedure, its recognizing when it needs to be done and having the balls to do it, especially knowing everybody in the hospital will second guess your decision for a month.

 

[bartleby]

Sometimes it just comes down to whether you'd rather fill out a fill out a procedure note or a death certificate...

The hard part about a crich isn't doing the procedure, its recognizing when it needs to be done and having the balls to do it, especially knowing everybody in the hospital will second guess your decision for a month.

 

[mikecwru]

Sometimes it just comes down to whether you'd rather fill out a fill out a procedure note or a death certificate...

Speaking of difficulty airways, I had a guy come in in status last night who happened to have had a massive SAH. We put him down and he started desatting rapidly, bagging him with two people, then with an oral airway kept him dropping. I finally said "F' this" did a hail marry and tubed him in like 7 seconds before needing to change my underwear. Yes, you'll always have people second-guessing your decisions. ("Why did you sedate him ... was it just to get a CT scan?")

When you have someone coming in hypoxic and crashing it's actually a lot less stressful than when you have somone that was 100% and you caused them to drop.

mike

 

[ERMudPhud]

The worst airway case I ever heard of at M&M was a little girl who aspirated a long cylindrical bead. The bead had a little hole in the middle through which a very small amount of air could pass. Probably equivalent to an 18g needle. The bead landed in her trachea resting on the carina and extending nearly to the level of cords, filling her airway. She came in stridorous with the only air moving through the little hole in the bead. Couldn't tube her because there was no where to put the tube. Couldn't get a hold of the bead to pull it out. Couldn't do transtracheal jet ventillation because the needle just hit the bead. Finally went to the OR where they had a great deal of trouble establishing a surgical airway and removing the bead. She ended up with a trach done very low into the mediastinum. Fortunately she was able to maintain her sats above 90% on 100% FiO2 and they were able to provide general anesthesia via mask during the procedure. If I could remember the C02 on her blood gas around the time she was in the OR though I recall it would have easily set a record on our record lab values sticky.

 

[spyderdoc]

The worst airway case I ever heard of at M&M was a little girl who aspirated a long cylindrical bead. The bead had a little hole in the middle through which a very small amount of air could pass. Probably equivalent to an 18g needle. The bead landed in her trachea resting on the carina and extending nearly to the level of cords, filling her airway. She came in stridorous with the only air moving through the little hole in the bead. Couldn't tube her because there was no where to put the tube. Couldn't get a hold of the bead to pull it out. Couldn't do transtracheal jet ventillation because the needle just hit the bead. Finally went to the OR where they had a great deal of trouble establishing a surgical airway and removing the bead. She ended up with a trach done very low into the mediastinum. Fortunately she was able to maintain her sats above 90% on 100% FiO2 and they were able to provide general anesthesia via mask during the procedure. If I could remember the C02 on her blood gas around the time she was in the OR though I recall it would have easily set a record on our record lab values sticky.

Your's was lucky. The one we had during residency was a toddler w/ a ball bearing in the same spot. Kid died despite huge effort....

 

[PhantomShadow]

I intubated a morbidly obese patient yesterday (600 lbs) who had a neck the size of my thigh. In Kalamazoo, we have a difficult airway box as well as fiberoptic scopes available. I was able to easily intubate the patient with DL but did use the fiberoptic scope to aid in placement confirmation (quickly done and helps in comfort level using the scope). Sterilizing the scope is a pain but we have an established protocol to have it swapped out expeditiously by the same method we replace crash carts. Despite all of the methods at our disposal to intubate a patient, I still feel that the ability to provide appropriate BVM ventilations is key. If you can BVM a patient, you have the luxury of time to adequately prepare for the airway. More times than not, airways are not 'gotta get it right now'. And after reading the above posts, I will be carrying crich supplies with me now as well.

 

[neutropeniaboy]

The hard part about a crich isn't doing the procedure...

Sounds like you haven't done enough of them.

 

[spyderdoc]

Sounds like you haven't done enough of them.

Sounds like you have done too many...