Question from an EM resident

[NewmansOwn]

Hi guys. EM PGY-1 here, on my anesthesia (read: really just airway and none of the other stuff you do) month, with a question on DL technique.

In my ED, as in most these days, we use VL almost exclusively for intubations, which I'm starting to get a good handle on. However, in the OR, our anesthesiologist colleagues prefer DL with Mac for first-attempt. I respect this and want to become facile with the practice. I am able to comfortably get the tongue out of the way and the Mac blade seated in the vallecula with a good view of the epiglottis, but then have difficulty getting a clear view of the cords. A nurse has provided cricoid pressure for me most of the times, and this provides me with a good enough view that I can almost always successfully pass the tube. But I don't feel as though I should need this very often - most of the anesthesiologists, unsurprisingly, require no cricoid pressure to pass the tube with DL.

I suspect the problem is in my "lift" with the scope, no? My question - once seated correctly, should the scope be lifted more straight (ie - towards the pt's toes) or up (as in, straight off the table), or is in an equal combination of both directions (that is, upward and outward, at a 45% angle from the table)?

Any tips for better visualizing the cords themselves once I have a solid view of the epiglottis would be much appreciated, from you who do it much more frequently that I (hopefully) every will.

Thanks.

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[countingdays]

My bet is that you need to place the blade deeper into the vallecula.

 

[Agast]

Are you putting the patient in the sniffing position (extending the head)? My guess is that's one step you're not using as much with video laryngoscopy so when it comes to the direct approach you skimp on it.

 

[Sublimazing]

My bet is that you need to place the blade deeper into the vallecula.

Agreed. If you're seeing epiglottis with good tongue sweep/sniff position/solid handle elevation (at 45 like you said) then I bet the blade isn't as far in the vallecula like you think.

Three tips (from a dental resident so take them at your own peril)

1. When you get that same view again advance further with the laryngoscope deeper into the vallecula

2. After your scope is in pick the patient's head up with your right hand on the occiput/neck and manipulate the elevation/angle it to see if you can get a better view

3. Try a miller. If you're seeing epiglottis every time you can just flick it out of the way with a straight blade

Good luck!

 

[deleted171991]

Make sure the patient is in sniffing position (use blankets). Many of the so-called difficult intubations can be related to poor positioning.

Open the mouth wide. Do not be afraid to subluxate the jaw, if needed.

When using a Mac blade, make sure you are neither too far out, nor too far in! Many times one has an "anterior" or "difficult" airway, it's mostly poor patient or blade positioning.

Use a Miller blade, which might be more intuitive to somebody who hasn't trained with a Mac.

It doesn't matter what you use to intubate, as long as you can recognize your limits before inducing the patient. Always have at least one (if not two or three) good backup plan(s), ready to go (that's where knowledge of many alternative intubating/ventilating techniques comes in handy).

 

[loveumms]

No offense but, it really bothers me when the ER residents in our institution come onto our service and expect to learn "intubation" and nothing else. Why would you limit your learning? Try and learn as much as possible, especially about the pharmacology of our medications (because one day you might very well be using those drugs … how do you think people go to sleep prior to intubations).

 

[cognitus]

No offense but, it really bothers me when the ER residents in our institution come onto our service and expect to learn "intubation" and nothing else. Why would you limit your learning? Try and learn as much as possible, especially about the pharmacology of our medications (because one day you might very well be using those drugs … how do you think people go to sleep prior to intubations).

I'd relax. If the EM residents know how to intubate, that's one less area the on call anesthesiologists have to go to. Besides, EM doctors have to know a LOT of other things. Now you want them to be anesthesiologists too?

 

[NewmansOwn]

Thank you for the excellent tips guys. They're thoughtful, and I'm certain they'll help.

No offense but, it really bothers me when the ER residents in our institution come onto our service and expect to learn "intubation" and nothing else. Why would you limit your learning? Try and learn as much as possible, especially about the pharmacology of our medications (because one day you might very well be using those drugs … how do you think people go to sleep prior to intubations).

I think you misunderstood me. I meant my first parenthetical sentence as a show of respect. It seems unreasonable to call what I'm doing an anesthesiology rotation, when I have been told I am just there to log as many tubes as possible - obviously, your specialty is so much more than that. I think my leadership is just focused on me learning our most critical and time-sensitive skill in as high-yield a way as possible. The finer points of neostigmine and glycopyrrolate are not really in our wheelhouse.

That being said, you do know we in EM use drugs to put people to sleep before intubating them, right? It's a rare RSI that doesn't involve an induction agent and a paralytic, at a minimum.

Anyway, this is your forum, not mine, so sorry I touched a nerve. If you have any productive advice for a beginner like me, I'd be really grateful.

 

[cognitus]

Thank you for the excellent tips guys. They're thoughtful, and I'm certain they'll help.



I think you misunderstood me. I meant my first parenthetical sentence as a show of respect. It seems unreasonable to call what I'm doing an anesthesiology rotation, when I have been told I am just there to log as many tubes as possible - obviously, your specialty is so much more than that. I think my leadership is just focused on me learning our most critical and time-sensitive skill in as high-yield a way as possible. The finer points of neostigmine and glycopyrrolate are not really in our wheelhouse.

That being said, you do know we in EM use drugs to put people to sleep before intubating them, right? It's a rare RSI that doesn't involve an induction agent and a paralytic, at a minimum.

Anyway, this is your forum, not mine, so sorry I touched a nerve. If you have any productive advice for a beginner like me, I'd be really grateful.

I wouldn't sweat it. Loveumms is just weird and uber sensitive for some reason. He also can't read. I and the other anesthesiologists completely understood you.

 

[inmyslumber]

To the OP, please take what loveumms says to heart. You may be earnest in your respect for our profession but we have seen too many "intubate and leave" ED residents rotate. These particular ED residents don't even make an effort to meet the patient prior to the airway.

More than a few times, in the trauma bay, when I let ED physicians take the airway, they don't demonstrate knowledge that an induction agent should be given before muscle relaxant. Then, after I correct them and patient is intubated, I ask what the ED physicians plan to give for sedation. Most times the response is "vecuronium"...I take this as a teaching opportunity but this is pretty basic information that only comes with thinking of your anesthesiology rotation as a chance to learn about more than just intubations.

An interested and involved ED resident on the anesthesiology rotation really stands out. I always tell the ED program director when one comes along.

 

[NewmansOwn]

To the OP, please take what loveumms says to heart. You may be earnest in your respect for our profession but we have seen too many "intubate and leave" ED residents rotate. These particular ED residents don't even make an effort to meet the patient prior to the airway.

More than a few times, in the trauma bay, when I let ED physicians take the airway, they don't demonstrate knowledge that an induction agent should be given before muscle relaxant. Then, after I correct them and patient is intubated, I ask what the ED physicians plan to give for sedation. Most times the response is "vecuronium"...I take this as a teaching opportunity but this is pretty basic information that only comes with thinking of your anesthesiology rotation as a chance to learn about more than just intubations.

An interested and involved ED resident on the anesthesiology rotation really stands out. I always tell the ED program director when one comes along.

Thank you, but the the fact that your emergency physicians are apparently complete idiots is not really relevant to me. Though I do feel bad for you that you have to deal with that.

And in our ED, we manage all airways primarily. We request and very much appreciate the help of our more experienced anesthesiology colleagues only on the most challenging airways that our own attendings can't handle.

 

[ketap]

newmansOwn: i am also an ED physician but i have really great interest to anesthesia..i believe all that have been said about the techniques are great..but i believe you have to put another consideration..that intubation in ED is sometime harder than when we intubate in the OR (elective operation)..i know this because i did both settings... and the key is to quick prepare any options available: other blade size, miller and mac, VL , suction, and bougie...i have VL in my ED, but i rarely used it since i preffered the DL...
oh ,don't forget that if u put mac to deep , you will push the epiglotis and it will block your view..take it off a bit and put it in the right place..changing to miller is a great choice too...did it when i intubated a fat guy with severe septic shock.. another trick: try bougie..
and just want to tell you that cricoid pressure is not for improving the view..yes, it can help..but the function of it is to prevent regurgitation..to improve the view..do BURP..

good luck

 

[rsgillmd]

Agreed. If you're seeing epiglottis with good tongue sweep/sniff position/solid handle elevation (at 45 like you said) then I bet the blade isn't as far in the vallecula like you think.
.......
2. After your scope is in pick the patient's head up with your right hand on the occiput/neck and manipulate the elevation/angle it to see if you can get a better view.........

Good luck!

In my view if you are having to lift the head after laryngoscopy, you probably didn't position them right to begin with. Ideally, you should spend that time up front. I tend to be particular about taking a few seconds to position them in the ear to sternal notch manner.

 

[deleted171991]

In my view if you are having to lift the head after laryngoscopy, you probably didn't position them right to begin with.

Either that, or s/he doesn't open the mouth properly. Typical beginner mistake, afraid/unable to subluxate the jaw.

 

[countingdays]

In my view if you are having to lift the head after laryngoscopy, you probably didn't position them right to begin with. Ideally, you should spend that time up front. I tend to be particular about taking a few seconds to position them in the ear to sternal notch manner.

I don't see the appeal of holding a patient's upper body in mid-air with a laryngoscope once you let go with your right hand to grab the tube. Call me crazy.

 

[norwood]

To answer the OP's question, 45 degrees - up and out, but never, never levering off the teeth. Make sure you get a good right-to-left sweep in at the beginning or you will deflect the tongue straight into your own path. IMHO the most common error new trainees make is to do a crummy sweeping motion. You want to sweep the whole tongue out of your way (while, again, being careful with the teeth) - not just the last inch or so, which I see a lot of trainees do. Then they advance the scope all the way in, get a sorta-kinda-usable view, and wonder why the whole thing is so hard.

And good luck, dude. Sounds like you have a good attitude about the whole thing. Hoover up as much knowledge as you can on each rotation and you'll be a powerhouse.

 

[NewmansOwn]

Thanks again guys. You've been gracious, patient and thoughtful with an outsider, and I'm grateful. I'll focus on patient positioning, thorough tongue sweep and depth of blade placement. Looking forward to Monday to get a chance to try it all out.

 

[Biochemist21]

The nature of how the OP's administrators chose to set up their "anesthesia rotation" is neither here nor there, but I do respect him/her for coming to this forum with a genuine question. Also conceding that I am only a 4th year med student with a whopping 11wks of anesthesia experience, I thought I'd offer a few tips I received which proved helpful early in my OR experiences.

As several others have recommended, make sure you adjust the head into the "sniffing position" (assuming no cervical pathology). I usually slightly extend the neck prior to inserting the blade, then scissor open the jaw with right hand, and sweep the tongue. Keeping the right hand on the dome/occiput I can adjust the sniffing position extension angle to get the best view.
(adequate visualization would be all but impossible in the left image given the lack of neck extension, vs. a straight shot to the cords with the neck extended in the right image).

-------->

I was also taught to initially slide the Mac a little deep so that the tip of the Mac is actually under the epiglottis, then slowly slide back the blade, waiting for the epiglottis to fall. When it does, then gently slide the Mac forward again and you'll be in the valecula every time (it's much easier to slide back on the blade while maintaining view versus trying to edge the blade forward if you're too shallow). Finally, if you aim the end of the handle for the point where the ceiling and wall meet, that's about 45deg and will generally keep you clear of the teeth.

Like I said, I'm just a 4th year, so don't shoot the messenger, but hopefully the OP might find some bit of this helpful.

 

[geogil]

Try a Miller blade, as others have mentioned. I find that the Mac can take up a lot of room in the mouth. Re: the ED that only gives vec for sedation, either this is more common than you would think, or you're at my place. I can't tell you how many folks come up from the ER "sedated" only with the 2 of midaz that was pushed for intubation. I see it on the floor too when our medicine colleagues may only push paralytic and a whisper of benzo. Granted, there are situations where that might be all you can/should do, but typically not in languishing ICU patients who have been downtrending for hours/days.

 

[Sublimazing]

In my view if you are having to lift the head after laryngoscopy, you probably didn't position them right to begin with. Ideally, you should spend that time up front. I tend to be particular about taking a few seconds to position them in the ear to sternal notch manner.

Well I think it's pretty obvious the OP is doing something wrong...that's the whole point of this thread...good chance it's positioning

 

[OPPforlife]

Transitional year intern at a family med residency here. I too can attest that I have seen the "vecuronium sedation" more than once. I'm pretty sure once the pt was still in the ER and the nurse literally kept paging me a million times about the patients elevated BP until I finally figured out we were doing the classic vec sedation...so scary.


Sent from my iPhone using Tapatalk

 

[Sublimazing]

I don't see the appeal of holding a patient's upper body in mid-air with a laryngoscope once you let go with your right hand to grab the tube. Call me crazy.

It's just to reposition if it wasn't optimal to begin with, though intubating in mid air would be impressive

 

[wickedskillz]

Good luck, way to seek advice. As you get more comfortable with it, it might be worth your time to ask an ENT doc their opinion too. I think it's always worth hearing different opinions and implementing what works for you into your practice. You have a great attitude though, keep practicing and looking for ways to improve and you'll do great!

 

[countingdays]

It's just to reposition if it wasn't optimal to begin with, though intubating in mid air would be impressive

Yeah, I'd position them before putting the blade in the mouth and if you need to reposition, remove the blade, reposition, then take another look.

 

[pinipig523]

Do you guys have a good picture of proper sniff position? During my anesthesia rotations, we used to do sniff positions - but since then, we (or I mean, now that I am alone... "I") do not. Although I haven't (knock on wood) had intubations that I have not been able to get, it'd be nice to get some proper sniff position tips from the pros (like how many blankets, exactly where on the patient's occiput and upper body, neck... etc).

I usually use MAC, I do a very good tongue sweep and I just lodge right into the valecula and maybe a little BURP and voila - cords.

If I can add the sniff position to my arsenal, I'd love it.

Thanks -

 

[BobBarker]

I use a prone pillow frequently to help with positioning. I ask the patient to tilt their dead back at me as the propofol goes in. The prone pillow is helpful to use on those with big chest wall appendages.

 

[loveumms]

I wouldn't sweat it. Loveumms is just weird and uber sensitive for some reason. He also can't read. I and the other anesthesiologists completely understood you.

I am not weird or uber sensitive. I've been "training" ER residents on how to intubate for years. Many of them come onto our service and think the only thing we do is intubate. I actually had a second year ER resident tell me she didn't need to know any of the medications we use. Her exact words were, "why would I need to learn about them? the attending always pushes the drugs". HMMMM - I wonder why?

 

[loveumms]

I'd relax. If the EM residents know how to intubate, that's one less area the on call anesthesiologists have to go to. Besides, EM doctors have to know a LOT of other things. Now you want them to be anesthesiologists too?

WRONG - if they are only learning to intubate and nothing about the how, why and with what then we are doing them a huge disservice. I don't know about you but, I don't like going to hyperkalemic arrests because some doc who "can intubate" pushed sux on a patient who has been bed ridden patient for the last six years. Or even worse, someone who pushes vecuronium on a 250kg man with a MP IV, neck circumference the size of my waist who just ate a hamburger and a milkshake. I could go on and on about the things I've seen.

Great, that person can intubate but if they don't know what medications to use and WHY then I didn't do my job as an academic attending teacher.

 

[loveumms]

Thank you for the excellent tips guys. They're thoughtful, and I'm certain they'll help.



I think you misunderstood me. I meant my first parenthetical sentence as a show of respect. It seems unreasonable to call what I'm doing an anesthesiology rotation, when I have been told I am just there to log as many tubes as possible - obviously, your specialty is so much more than that. I think my leadership is just focused on me learning our most critical and time-sensitive skill in as high-yield a way as possible. The finer points of neostigmine and glycopyrrolate are not really in our wheelhouse.

That being said, you do know we in EM use drugs to put people to sleep before intubating them, right? It's a rare RSI that doesn't involve an induction agent and a paralytic, at a minimum.

Anyway, this is your forum, not mine, so sorry I touched a nerve. If you have any productive advice for a beginner like me, I'd be really grateful.

Maybe I read your post wrong but, I've come across several ER residents who feel they should only learn to tube the patient when they come onto our service. Then I see those same residents flounder in the trauma bay when they don't know what meds to use or what to do when they encounter a difficult airway.

Of course I know you use medications for intubation. That was why I suggested you learn about more then just the act of intubating - like what medications to use, why and in what manner. It's not an RSI if it doesn't involve induction medications.

 

[cognitus]

WRONG - if they are only learning to intubate and nothing about the how, why and with what then we are doing them a huge disservice. I don't know about you but, I don't like going to hyperkalemic arrests because some doc who "can intubate" pushed sux on a patient who has been bed ridden patient for the last six years. Or even worse, someone who pushes vecuronium on a 250kg man with a MP IV, neck circumference the size of my waist who just ate a hamburger and a milkshake. I could go on and on about the things I've seen.

Great, that person can intubate but if they don't know what medications to use and WHY then I didn't do my job as an academic attending teacher.

I hope I never have to ask YOU for intubation advice

 

[NewmansOwn]

It sounds like you've had bad experiences with EM residents, loveumms. That's a shame to hear at a time when we're becoming more and more competitive and attracting some really bright candidates. I can assure you the residents at my program and others with which I am familiar are much better educated, more inquisitive and more eager to learn from anyone and everyone, especially anesthesia.

We take the drugs we use for intubation seriously and aggressively educate ourselves about them, as many of our departments had to fight hard to earn the right to use them without anesthesiology supervision by proving their proficiency. Some are still fighting for the right to use propofol, for instance, for conscious sedation, as it is technically considered 'general anesthesia' - my department's ability to use that has made hip reductions, et al, much quicker, as now we don't have to wait for the versed cocktail to wear off -- quick on, quick off.

Even as a PGY-1, I could discuss with you the merits and contraindications of etomidate, propofol and ketamine for induction, as well as succ vs roc vs vec for muscle paralysis. The evidence (or more accurately, lack thereof) for pre-treatment with atropine, lidocaine, etc is another hot topic. Furthermore, I've already been lucky enough to sedate patients of all ages for a variety of procedures using propofol, etomidate, ketamine, pentobarbital, versed (IV and intranasal, for the little ones!).

Please keep in mind, the more I know, the less I have to bother you. All I can say is, if your ER docs suck, make sure the leadership hears about it - the resident who told you she didn't need to know intubating drugs cannot be allowed to continue without a sharp change in attitude.

 

[deleted171991]

It sounds like you've had bad experiences with EM residents, loveumms.

I trained at a well-known academic hospital and I had absolutely the same experiences (they would be interested only in getting the tube in and getting out of the room). The medical students rotating in anesthesia had more and smarter questions than most EM residents. You are the exception to the rule, NewmansOwn.

I hope I never have to ask YOU for intubation advice

Aren't you cocky with an attending for somebody who's still on the residency interview trail? Aren't you afraid that one of us might recognize you, with your fancy MBA career before med school?

I wouldn't sweat it. Loveumms is just weird and uber sensitive for some reason. He also can't read. I and the other anesthesiologists completely understood you.

Stop acting like you are an anesthesiologist. You are not even a resident.

 

[NewmansOwn]

I trained at a well-known academic hospital and I had absolutely the same experiences (they would be interested only in getting the tube in and getting out of the room). The medical students rotating in anesthesia had more and smarter questions than most EM residents. You are the exception to the rule, NewmansOwn.

FFP and sublimazing, I did mean to thank you for the Miller advice (and the others who echoed it). I gave it a try today on an toothless old lady with a fairly anterior airway and it worked beautifully - I had a really nice view of the cords and slid the tube right in. Good call.

 

[deleted171991]

The next best thing you should do, while you are rotating in anesthesia, is to become good at the placement of an LMA (the more types the better). It will help you ventilate an unrecognized difficult airway after inducing the patient. Also, learn how to properly mask ventilate all kinds of difficult patients (poor mask fit, morbidly obese etc.). While we are at it, take a look at the ASA difficult airway algorithm and ask someone knowledgeable to explain it to you in detail; it contains many important questions and answers.

 

[ketap]

Do you guys have a good picture of proper sniff position? During my anesthesia rotations, we used to do sniff positions - but since then, we (or I mean, now that I am alone... "I") do not. Although I haven't (knock on wood) had intubations that I have not been able to get, it'd be nice to get some proper sniff position tips from the pros (like how many blankets, exactly where on the patient's occiput and upper body, neck... etc).

I usually use MAC, I do a very good tongue sweep and I just lodge right into the valecula and maybe a little BURP and voila - cords.

If I can add the sniff position to my arsenal, I'd love it.

Thanks -

hi..i believe that you can read about that in any airway textbook..as i recall, one of them said that the pillow must 8-10 cm tall (for regular, un-obese patient) ..i cannot tell you how much blanket since we don't know what you got..i suggest just do some of your own experiment..i did it and it gave me lots of benefits..especially i am working at ED too..i just want to tell you that please remember that there is a definition of "sniffing"..it is not just elevate your patient's head..but u should position your patient with a flexed neck and head extention...IMHO, this is the cause why we have hard time intubating the fat patients (not all ).. And i really love "pillows under the patient's back "method for this purpose (though it is not always possible to do it..hey, it is ER)

Maybe I read your post wrong but, I've come across several ER residents who feel they should only learn to tube the patient when they come onto our service. Then I see those same residents flounder in the trauma bay when they don't know what meds to use or what to do when they encounter a difficult airway.

Of course I know you use medications for intubation. That was why I suggested you learn about more then just the act of intubating - like what medications to use, why and in what manner. It's not an RSI if it doesn't involve induction medications.

although i am also an ED physician..i cannot say that loveumms wrong..he/she is absolutely right..i even think that the emergency doctors should really know their drug well..if not, how can we save our patients..i learned that so many things can happened in ED, so i believe prepare for it like what Loveumms said is a crucial thing..great advice!!

 

[norwood]

The next best thing you should do, while you are rotating in anesthesia, is to become good at the placement of an LMA (the more types the better). It will help you ventilate an unrecognized difficult airway after inducing the patient. Also, learn how to properly mask ventilate all kinds of difficult patients (poor mask fit, morbidly obese etc.). While we are at it, take a look at the ASA difficult airway algorithm and ask someone knowledgeable to explain it to you in detail; it contains many important questions and answers.

Boldfaced part of it, because it deserves it.

I trained with oldschool guys who beat proper mask technique into our heads. You may fail to intubate, you may fail to get the LMA in, your equipment may add to the endless list of creative ways that equipment fails at the least opportune time. But if you can get oxygen into those lungs with a mask, your patient will survive until you get to a plan that works.

 

[loveumms]

I hope I never have to ask YOU for intubation advice

I hope so too since you didn't understand the response. Just because you have seen some anesthesia doesn't make you an expert, nor does it make you experienced.

It's funny how bold people become when they are anonymous.

 

[cognitus]

I hope so too since you didn't understand the response. Just because you have seen some anesthesia doesn't make you an expert, nor does it make you experienced.

It's funny how bold people become when they are anonymous.

I'm not experienced but I want to be. Your original post rubbed me the wrong way because the OP was simply asking for intubation advice and because of that, you assumed he wasn't concerned or cared about induction agents or the other medications applied before DL. I hope I can ask for similar advice on here and not get attacked. Your original response just sounded a little premature to me. I read your subsequent response and I approve. It's all good now.

 

[deleted171991]

I read your subsequent response and I approve. It's all good now.

We are all so grateful, oh, Great One!

 

[cognitus]

We are all so grateful, oh, Great One!

lol