Positioning

[24GaugeEJ]

EMCrit Podcast 226 - Airway Update - Bougie and Positioning

I am curious as to how much of this article/podcast is really news; particularly the section regarding patient positioning. I’ve been a paramedic for nigh on half a decade and have worked in both the prehospital and ED settings - though really looking forward to starting medical school this fall. During paramedic school and additional training for maintainence of my license, I was lucky enough to spend a fair amount of time in the OR with an anesthesiologist. The first anesthesiologist I tagged along with really emphasized positioning of the patient when ventilating with a bvm, and during intubation — the so-called “flextension” noted in the article. We even held the laryngoscope in place while gently lifting the patient’s head up and down to see how dramatically the view can vary just based on the patient’s positioning.

Whenever I have been fortunate enough to intubate in the ED, I follow the instructions of the physician who is nice enough to allow me to practice this skill, though I always try to position the patient with a towel or two under his head and do my best to be gentle with the blade. That being said, I have seen some very idiosyncratic approaches over the past few years; e.g. long towel roll placed between the patient’s shoulders along the spine, patient laid flat with head hanging back off the cot, etc...

So, what’s the proper approach? It seems like this is fairly basic, but I’ve rarely seen this in the prehospital or ED settings (neither medic nor doc), and it always makes me a little uncomfortable. Don’t really like to speak up about this stuff when I’ve done 50 tubes and the doc has done 500. Happy to see this on emcrit, in any case. Thought I’d ask the experts.

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[anbuitachi]

EMCrit Podcast 226 - Airway Update - Bougie and Positioning

I am curious as to how much of this article/podcast is really news; particularly the section regarding patient positioning. I’ve been a paramedic for nigh on half a decade and have worked in both the prehospital and ED settings - though really looking forward to starting medical school this fall. During paramedic school and additional training for maintainence of my license, I was lucky enough to spend a fair amount of time in the OR with an anesthesiologist. The first anesthesiologist I tagged along with really emphasized positioning of the patient when ventilating with a bvm, and during intubation — the so-called “flextension” noted in the article. We even held the laryngoscope in place while gently lifting the patient’s head up and down to see how dramatically the view can vary just based on the patient’s positioning.

Whenever I have been fortunate enough to intubate in the ED, I follow the instructions of the physician who is nice enough to allow me to practice this skill, though I always try to position the patient with a towel or two under his head and do my best to be gentle with the blade. That being said, I have seen some very idiosyncratic approaches over the past few years; e.g. long towel roll placed between the patient’s shoulders along the spine, patient laid flat with head hanging back off the cot, etc...

So, what’s the proper approach? It seems like this is fairly basic, but I’ve rarely seen this in the prehospital or ED settings (neither medic nor doc), and it always makes me a little uncomfortable. Don’t really like to speak up about this stuff when I’ve done 50 tubes and the doc has done 500. Happy to see this on emcrit, in any case. Thought I’d ask the experts.

sniffing position. different people have different positions. i usually put blankets underneath the shoulders.

 

[dchz]

skip the shoulder roll, just lift up the head by the mandible with the blade until you get a sniffing position.

 

[24GaugeEJ]

skip the shoulder roll, just lift up the head by the mandible with the blade until you get a sniffing position.

Careful, I haven’t figured out this Dunning-Kruger thing well enough to tell whether you’re serious.

 

[drmwvr]

Positioning and techniques and devices don't mean anything when they are emphasized more than a real live honest to goodness thorough airway exam. For those that would say that is stating the obvious, I would say, I wish it were.

 

[deleted162650]

I would try not to take too much intubating advice from EM docs. The anesthesiologist knew what he was talking about, and was cool enough to actually demonstrate it for you. Honestly, how much easier did you find it when the pt was positioned properly in the OR compared to the poor positioning you worked with in the ED??

 

[anbuitachi]

I would try not to take too much intubating advice from EM docs. The anesthesiologist knew what he was talking about, and was cool enough to actually demonstrate it for you. Honestly, how much easier did you find it when the pt was positioned properly in the OR compared to the poor positioning you worked with in the ED??

May not be much if using the glide

 

[deleted162650]

May not be much if using the glide

Even with the glide positioning helps quite a bit. Just not as crucial.

 

[narcotics999]

May not be much if using the glide

It helps too, especially if pt has small chin, small mouth opening and a protruding adam's apple.

 

[24GaugeEJ]

I would try not to take too much intubating advice from EM docs. The anesthesiologist knew what he was talking about, and was cool enough to actually demonstrate it for you. Honestly, how much easier did you find it when the pt was positioned properly in the OR compared to the poor positioning you worked with in the ED??

Much, much easier. The first tube I ever did, he literally said, “put the blade straight in and push forward.” The view was textbook and I just assumed all intubations were that simple. From there we worked on bagging and positioning and I started to understand how well that first patient had been prepped. I mean, it seemed like just the act of opening the mouth afforded a look at the cords.

That being said, the ED docs have been really cool to work with as well. More effort seems to go into brute force or glidescope though. I was just surprised to see this big podcast/article demonstrating sniffing position.

 

[lobelsteve]

Jackson frame, fairly high, ipsilateral rotation. No lead, but maybe a bouffant and mask. But now there are cameras in all the ORs.

 

[deleted162650]

Jackson frame, fairly high, ipsilateral rotation. No lead, but maybe a bouffant and mask. But now there are cameras in all the ORs.

Uhhh, WTF are you talking about?

 

[lobelsteve]

Uhhh, WTF are you talking about?

Positioning, man.

 

[anbuitachi]

Even with the glide positioning helps quite a bit. Just not as crucial.

It helps too, especially if pt has small chin, small mouth opening and a protruding adam's apple.

Definitely helps, but definitely less crucial since the whole point of sniffing is aligning the cords to your eyes but with the glide the camera is now the 'eyes' so sniffing is less important.
I find sniffing to be most helpful for MAC blades, less important for millers,

 

[narcotics999]

Definitely helps, but definitely less crucial since the whole point of sniffing is aligning the cords to your eyes but with the glide the camera is now the 'eyes' so sniffing is less important.
I find sniffing to be most helpful for MAC blades, less important for millers,

To see the cord, yes, less important. However, sometimes the difficult part is to angle the tube to the cord, even with the rigid stylet. Then positioning helps a lot.