cricoid pressure for awake intubation

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apma77

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any one doing cricoid pressure for awake (true awake with just topical)FOI?

also....whats the consensus on a transtracheal block killing off airway reflexes if its done prior to awake fiber intuabation?

any thoughts???
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apma77 said:
any one doing cricoid pressure for awake (true awake with just topical)FOI?

also....whats the consensus on a transtracheal block killing off airway reflexes if its done prior to awake fiber intuabation?

any thoughts???
Click to expand...

I don't believe cricoid pressure performed during UNAWAKE intubations makes a difference.

Let alone during awake intubations.
 
to the best of my knowledge, there's no old or recent study that verifies efficacy/benefit for utilizing sellick's maneuver...
it is just ingrained during education to use..
it's sort of like asking why, and mum says "because i said so"...
 
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Loss of tracheal reflexes is NOT the same as loss of LOWER airway reflexes.
 
apma77 said:
any one doing cricoid pressure for awake (true awake with just topical)FOI?

also....whats the consensus on a transtracheal block killing off airway reflexes if its done prior to awake fiber intuabation?

any thoughts???
Click to expand...
Topical anesthetics and airway blocks do decrease airway protective reflexes and do increase the risk of aspiration if the patient vomits.
This is always a concern when you do awake intubations on patients with high risk for aspiration, but like everything we do you try to balance risk and benefit.
 
apma77 said:
any one doing cricoid pressure for awake (true awake with just topical)FOI?

also....whats the consensus on a transtracheal block killing off airway reflexes if its done prior to awake fiber intuabation?

any thoughts???
Click to expand...

You could argue either way on this. Personally, I don't like transtracheals. I use nebulized lidocaine, cetacaine spray into the mouth, then spray some more lidocaine on the cords through the FOB once I see cords. Usually works well if the patient also receives some IV sedation.

And I don't use cricoid for awake intubations. The fact that they are awake means they can protect their airway in case they vomit, so I don't see the need to use cricoid.
 
apma77 said:
any one doing cricoid pressure for awake (true awake with just topical)FOI?

also....whats the consensus on a transtracheal block killing off airway reflexes if its done prior to awake fiber intuabation?

any thoughts???
Click to expand...

The only reason I would consider cricoid is if I wanted to manipulate the cords into my field of view. I've never needed to do this on an awake FOI.

As for transtracheals, if you can safely identify the anatomy (i.e. no goomba vascular tumor sitting on their trachea), I love to do them. I did 5 in about 2 weeks, and each one was super comfy. Quite remarkable actually to have the tube slip in, NO coughing at all, and the pt is happily cooperative for their "post intubation neuro check" :laugh:. I only :laugh: because they manipulate the neck a heckuvalot more during positioning and motors than I typically would do with a DL.

But yes, in theory these pts would not have the reflexes to cough as well if they aspirated.

And Mil, could you clarify the 'deep airway' versus 'tracheal' comments? I'm not sure what you're getting at.
 
Your trachea can be numb, but that doesn't mean your bronchi and lower airways will be numb.

You can have a tube in place while be able to cough when secretions (or vomit) reach into the bronchi>>>>resp bronchioles>>>>

IceDoc said:
The only reason I would consider cricoid is if I wanted to manipulate the cords into my field of view. I've never needed to do this on an awake FOI.

As for transtracheals, if you can safely identify the anatomy (i.e. no goomba vascular tumor sitting on their trachea), I love to do them. I did 5 in about 2 weeks, and each one was super comfy. Quite remarkable actually to have the tube slip in, NO coughing at all, and the pt is happily cooperative for their "post intubation neuro check" :laugh:. I only :laugh: because they manipulate the neck a heckuvalot more during positioning and motors than I typically would do with a DL.

But yes, in theory these pts would not have the reflexes to cough as well if they aspirated.

And Mil, could you clarify the 'deep airway' versus 'tracheal' comments? I'm not sure what you're getting at.
Click to expand...
 
militarymd said:
Loss of tracheal reflexes is NOT the same as loss of LOWER airway reflexes.
Click to expand...

Yes.

Furthermore, the risk of aspiration has to do with regurgitation of stomach contents in the pharynx mainly during RSI, not a numb trachea. Chemical trauma to the respiratory system being the main concern.

No need to do cricoid pressure during an awake FOI. Have never done it, nor ever seen anyone do it who's done an awake FOI. If the patient's not completely unconscious and still has a good LES tone, there's no point. Besides, as Jet mentions, the "evidence base" for cricoid pressure in and of itself is pretty weak.

-copro

P.S. Is it okay to be banging a hot, 24-year-old, blonde OB nurse with really big boobies? Just curious.
 
I was also wondering about the risk of aspiration after airway nerve blocks, as mentioned in a board review book. The answers I got were:
1. Transtracheal spray (BTW, I almost always do it if accessible) blocks sensory nerves, leaving motor function intact.
2. I pt is awake, he/she will know and protect him/herself from vomits.
So, that is not a concern.
 
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xyzdoc said:
I was also wondering about the risk of aspiration after airway nerve blocks, as mentioned in a board review book. The answers I got were:
1. Transtracheal spray (BTW, I almost always do it if accessible) blocks sensory nerves, leaving motor function intact.
2. I pt is awake, he/she will know and protect him/herself from vomits.
So, that is not a concern.
Click to expand...
If the airway is numb enough for you to insert a scope and an ETT without much resistance, what makes you think the airway will be sensitive enough for the patient to protect his airway if he vomits?
 
When I worked in the ICU, I did witness a few awake intubations. I don't recall any of them being done with any cricoid pressure.
 
xyzdoc said:
The rationale is that "When you vomit, you don't breath if you are awake."
Click to expand...
You might not breath while you are vomiting but if you have good topical anesthesia + good airway blocks you won't even know that there is material sitting on top of your airway waiting to be aspirated, actually when you anesthetize the airway patients very frequently aspirate their saliva.
And if you are going to count on "lower airway reflexes" it will be already too late because even if you cough when the vomitus had reached your distal airway you would still end up with aspiration pneumonia.
So, I wouldn't say that it is safe to anesthetize the airway in a patient with high aspiration risk but if you are anticipating a difficult intubation you might be willing to take the small risk of aspiration versus the risk of loosing the airway if you induce GA.
I don't think cricoid pressure is helpful here though.
 
blotto geltaco said:
Is this the first piece of @ss you have ever gotten or something? Most dudes don't need to brag on an anonymous internet forum about getting some.
Click to expand...

Yes. It's the first piece of tail I've ever gotten. I was a virgin until two weeks ago. In fact, I never saw a naked woman before this chick. Even in the OR when they were prepping the patient, Iused to avert my eyes.

Lighten up, Francis.

This chick is hot. I got dumped by my ortho girlfriend about six months ago. Been a bit of a dry spell. Lotta dudes been eyeballing the current fling. Now, gotta keep it on the lodi because of the whole "delicate" situation, and it clearly ain't a permanent arrangement. Tongues would wag at the daily grind. And, I hate that ****. This is as safe of a place as anywhere to brag. So, don't playa hate just because you're still banging the same ole hag. Just refer to me, from here on out, as McLovin.

-copro
 
coprolalia said:
Yes. It's the first piece of tail I've ever gotten. I was a virgin until two weeks ago. In fact, I never saw a naked woman before this chick. Even in the OR when they were prepping the patient, Iused to avert my eyes.

Lighten up, Francis.

This chick is hot. I got dumped by my ortho girlfriend about six months ago. Been a bit of a dry spell. Lotta dudes been eyeballing the current fling. Now, gotta keep it on the lodi because of the whole "delicate" situation, and it clearly ain't a permanent arrangement. Tongues would wag at the daily grind. And, I hate that ****. This is as safe of a place as anywhere to brag. So, don't playa hate just because you're still banging the same ole hag. Just refer to me, from here on out, as McLovin.

-copro
Click to expand...

Hey Cop, I swear I posted my response before I read yours!

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAH
 
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