your approach in intubating this hypoxic patient?

[Arch Guillotti]

Miller 4 vs. Glidescope +/- bougie.

Why do you use a miller 4 versus a miller 3?

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[Arch Guillotti]

McNinja and I talked about something relevant the other day - does anyone have any data or anecdotal experience putting the bougie through an LMA?

I guess it could be done but it doesn't seem ideal.

Some LMA's have barriers to prevent an ET tube being placed through it.

Intubating LMA is much better if you have access to one.

 

[Rendar5]

never used bougie with glidescope. is using bougie with glidescope straightforward? what about using it with regular et tube stylet.

i find the rigid stylet for the glidescope annoying at times (e.g., i can't advance past a point with more of a comfort zone).

If you're using a regular ET tube stylet, you need to go for a bigger curve than athe standard hockey puck your'e used to. almost a slight U shape. It took some getting used to but now the rigid stylet is second nature. just gotta have a second user hold the handle in place while you advanced the tube off of it.

 

[FDNewbie]

I thought I was pretty clear. What part didn't you understand?

You said my comment wasn't accurate at all. I think for the reasons mentioned above, my comment is pretty accurate, although it doesn't hold true in all situations. Ie, while most of our intubations are urgent/emergent, most of yours are scheduled/elective. So different rules & procedures apply. That's all I'm sayin.

Why do you use a miller 4 versus a miller 3?

So am I the only person out there that uses a Miller 2 on pretty much every single adult? I've done several hundred intubations now, and I think I've used a Miller 3 hmmm...MAYBE twice? Definitely once that I can recall. For everyone else, I've found the Miller 2 to be more than adequate. Plus, since it's a lot shorter than a Miller 3, you can get more of an angle with it without damaging the lip & teeth.

 

[Lawsonc]

I confuse the Miller 4 with a Halligan tool late at night.



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[Groove]

In residency we had a psych patient that liked to perch open safety pins on her valecula. She got to wear she could take a Mil 4 with 2 of Versed and not even cough. Trained a whole generation of ENT docs.

Ha...I can imagine the scramble... "quick! somebody go grab the airway cart and get the longest damn blade you can find! She swallowed a Miller 3 with 5 of versed last time, let's go for 4 and 2 this time!" ...

Honestly, there are some times I'd reach for the Miller 4.....to lift the heart closer to the chest for better chest auscultation for instance..., or perhaps to test for lower esophageal sphincter tone, etc.., the list goes on...

 

[Arch Guillotti]

Honestly, there are some times I'd reach for the Miller 4.....to lift the heart closer to the chest for better chest auscultation for instance..., or perhaps to test for lower esophageal sphincter tone, etc.., the list goes on...

I would not even know where to look for a Miller 4. I don't really understand why anyone would use it since it is the same length as a Miller 3. In my experience almost everyone can be intubated with a Miller 2 although some anesthesiologists swear by the Miller 3 as their failsafe blade.

 

[Arch Guillotti]

Awake intubation?? Are you an anesthesiologist? If I tried an "awake" intubation in HALF my patients, they would DIE before I even had the awake/difficult intubation cart down here from Anesthesia. These patients come in TANKING, often after getting solumedrol, mult nebs, CPAP, the whole 9, and NOTHING is working, and sats are in the tanker as EMS brings 'em in the ED. And the guy's huffin & puffin so bad, he's only got a few more minutes goin before he'll get so hypoxic, go into respiratory failure, and brady arrest.

I understand you operate under very different constraints in the ED. A few minutes is all you need for an awake intubation although I doubt any ED residencies are teaching this.

 

[BADMD]

A few minutes is all you need for an awake intubation although I doubt any ED residencies are teaching this.

I certainly didn't learn the technique in residency. The one time I've tried it, was for a patient that I anticipated was going to be a challenge. I got our "anesthesia team" (3 CRNAs) on standby, topicalized and gave it a shot. I had to borrow a fancy tube from the CRNAs, but it worked like a charm.

 

[Arch Guillotti]

I will say this and leave it be because I don't have much of an interest in trolling the ED forum anymore.

I know the OR and ED and 2 different beasts.

The ED guys I work with do a pretty good job the vast majority of the time although we do go down there and bail those trolls out every now and then.

The OR is not always controlled and we do not always follow the difficult airway algorithm to the letter. Some of the more chaotic and challenging airways I have been involved in there was NO option of waking the patient up.

So that's pretty much all I was saying. Hence why you can't apply all the Anesthesia rules & methods in the ED. While some may very well be applicable (the basics never change), there are other constraints & limitations that make other rules & methods inapplicable & unrealistic in the ED environment.

Because as mentioned above, the algorithm calls for things like LMAs, doing cases under MAC, and awake intubations. That's not what we're dealing with in the ED. Here's the algorithm I'm referring to:

I think maybe I wasn't clear in my earlier response. You're referring to an ED doc's backup/rescue devices (and what some of us may call OUR ED difficult intubation algorithm). My earlier comment was in response to the Anesthesiologist's comment, so I was speaking in terms of HIS Difficult Intubation Algorithm (the flowshart above), which again, is VERY different than our stepwise approach, and has options not applicable to the ED at all. My simple point was, you can't take stuff like that and just say "well you shoulda gone down that pathway in the ED" cuz it's not MADE for the ED, and much of it isn't an option & doesn't apply.

And I agree with you 100% that we should have bougies, LMAs, and some version of video-assisted intubation (I'm a big fan of the C-MAC because it has all the features of the Glidescope but is a MUCH better educational tool as well).

Hopefully that clears up what I was trying to say.

 

[Groove]

I would not even know where to look for a Miller 4. I don't really understand why anyone would use it since it is the same length as a Miller 3. In my experience almost everyone can be intubated with a Miller 2 although some anesthesiologists swear by the Miller 3 as their failsafe blade.

It might depend on the supplier/manufacturer. That one lists 4-207mm vs 3-192mm. Either way, I agree. I can count the times I've wanted a miller 3 vs a 2 and usually didn't have any other reason than I wanted a slightly wider miller blade. Either way, I don't think I've ever been as comfortable with a miller vs a mac. I think you guys tend to have more facile with the blade but sometimes you just gotta use it. Either way, I generally carry a mac 3 and miller 2 for the majority of adult intubations.

I'm pretty sure they stock more miller 4's in large animal vet clinics than in ED's.

 

[iridesingltrack]

I certainly didn't learn the technique in residency. The one time I've tried it, was for a patient that I anticipated was going to be a challenge. I got our "anesthesia team" (3 CRNAs) on standby, topicalized and gave it a shot. I had to borrow a fancy tube from the CRNAs, but it worked like a charm.

Does this statement reflect the majority? I guess I am somewhat surprised that people may not be learning awake intubation in EM residency...it is part of our didactic and simulation curriculum and something that is used in the ED when needed. Fiber optic nasal tracheal, fiber optic oral tracheal through a Williams airway, and awake VL/DL are all taught and used as indicated.

Also, in the nearly 3.5 years I've been at my shop, I've not seen or heard of anesthesia coming down to intubate one of our patients. If push came to shove, I'd have no problem calling or supporting someone in calling anesthesia to come help. I guess we are fortunate to have a vast array of toys in our ED and are trained to use them.

BTW, I highly recommend Ron Walls book Manual of Emergency Airway Management. In it, Dr. Walls provides ED specific algorithms that do not end in "cancel/suspend case" but does include awake intubation.

OP, the case you presented is complex to be sure. Intubating the hypoxic patient that is difficult to preoxygenate is always an entertaining affair. I have to agree with some of the posters above however, based on your description above this patient may have done well with NIPPV. But, another option that you could also try is delayed sequence intubation (DSI). It is best described here: http://emcrit.org/podcasts/dsi/.

Nice job handling the masseter spasm vs under sedation. I no longer use etomidate only in my intubations as I have found the intubating conditions to be very subpar. Honestly, I am not a believer that at the induction dose of 0.3mg/kg that people still are breathing adequately to sustain life anyway, especially if they already have respiratory failure. I prefer either full-on RSI, or ketamine (I have not done a precedex intubation but would love too) vs awake look if I want to keep them breathing.

Great post and discussion; I like the clinical cases.

iride

 

[FDNewbie]

In my experience almost everyone can be intubated with a Miller 2

Glad to see I'm not alone

I understand you operate under very different constraints in the ED. A few minutes is all you need for an awake intubation although I doubt any ED residencies are teaching this.

I dunno about any, but it certainly isn't taught in my residency program. And the Anesthesia difficult airway cart (with the bronchoscope) rests with - you guessed it - Anesthesia. We have our bag 'o tricks though in the ED though (bougie, LMA, Rich Levitan's telescoping blade (forget what the real name is), intubating LMA, lighted stylette).

I will say this and leave it be because I don't have much of an interest in trolling the ED forum anymore.

Your comments are always welcome though

I know the OR and ED and 2 different beasts.

Couldn't agree more.

The ED guys I work with do a pretty good job the vast majority of the time although we do go down there and bail those trolls out every now and then.

That's inevitable. And we're always happy to have ya accessible.

The OR is not always controlled and we do not always follow the difficult airway algorithm to the letter. Some of the more chaotic and challenging airways I have been involved in there was NO option of waking the patient up.

Fair enough.

Does this statement reflect the majority? I guess I am somewhat surprised that people may not be learning awake intubation in EM residency...it is part of our didactic and simulation curriculum and something that is used in the ED when needed. Fiber optic nasal tracheal, fiber optic oral tracheal through a Williams airway, and awake VL/DL are all taught and used as indicated.

I can't speak for the majority, but definitely not taught to us. Would be cool to learn though. We do have a nasotracheal fiberoptic scope in the ED though, which can just as well be used for the orotracheal route.

Also, in the nearly 3.5 years I've been at my shop, I've not seen or heard of anesthesia coming down to intubate one of our patients. If push came to shove, I'd have no problem calling or supporting someone in calling anesthesia to come help. I guess we are fortunate to have a vast array of toys in our ED and are trained to use them.

I think a lot of that depends on how confident your faculty are, and your hospital protocol is (based on negative outcomes, politics, etc). I was just discussing this the other day, because I think it's sad that once there's difficulty intubating the patient, it's an immediate call to Anesthesia. Why don't you let the ED go through the (ED) difficult intubation pathway, and troubleshoot until you actually NEED help, vs. just defaulting to "oh we'll call Anesthesia now." Cuz if you're good, and you can't tube cuz you have no view etc, Anesthesia's gonna have the same trouble, and be doing the same thing you're doing; going down the pathway. We can do that too

 

[Painter1]

I want to thank everyone who has posted input. I wanted to hear both from er docs and anesthesiologists as i don't think anyone would argue that anesthesiologists are the most experienced with the airway.

in terms of some comments, a couple noted that the patient may have not required intubation, that would be true if it weren't a trauma patient. the patient fell down an endless staircase and qualified for a trauma activation. the surgeons wanted a definitive airway before they continued with their assessment. i actually mentioned bipap, but they wanted something definitive especially since they were taking him to cat scan.

after gathering you guys information and talking to others, i would approach a similar patient as follows:

I would place a second oxygen source by applying a nasal canula at 15 liters on top of the non-rebreather (got this from one of my ex-attendings i spoke with after this case). This has been shown to increase o2 in a patient like i had.

i would go straight to etomidate AND roccuronium and use the glidescope at first offering. I would have a bougie at the side in case i have a hard time passing the rigid stylet.

If i can't intubate or ventilate at this point, I would drop an LMA. If the patient still can't ventilate or oxygenate with LMA, i would ask the surgeons who were there to perform a cric.

What i learned is that etomidate by itself can get you into a difficult situation (e.g. paitent biting down, masseter spasm).

Lastly, in a non-trauma patient without possible intracranial injury (i know this in controversial [head injury and ketamine]), i would use ketamine dosed at 1mg/kg without paralytic, try bipap if the nasal canula trick is not working, then take a look with glidescope.

i'm kinda embarressed to say, but i've never used a miller blade. maybe i should use it for my next intubations to get a hang of it.

 

[Groove]

i'm kinda embarressed to say, but i've never used a miller blade. maybe i should use it for my next intubations to get a hang of it.

Try it out. I only use it first on kids. I remember when I was an intern doing my anesthesia rotation that I was going to be the one EM guy who always used a miller 2...just to be different, because everyone used macs down there and I kept hearing whisperings "miller? no, don't use that, only anesthesiologists can use millers very well...it takes facile and lots of practice..). All my tubes went pretty easy that year and when I started in the ED, I kept using miller...until we had a messy, fat, trauma pt come in and I couldn't see diddly squat with that damn narrow blade. Blood and redundant soft tissue drooping and pushing everywhere. I've used a mac first ever since. I'll shove a mac 4 in some of those big fat ones and even lift the epiglottis with the tip of that, just for the extra view. Sometimes though I just can't hockey puck the tube under a big 'ol floppy epiglottis, or even bring the base of the cords into view by channeling the power of Thor with my thyroid pressure, BURP, vallecula thrust (did I make that up?), etc.. so I'll bag 'em up and use the miller which usually works just fine and easy like it always used to do but I guess habits die hard.

I shouldn't have even used the miller that day anyway on the trauma pt, poor choice, then I could have realized my dream of being the cool EM guy who "always uses miller". Alas, robbed of my dream by the fat, bloody neck and now that I think back, probably poor technique, at the time, on top of that.

Sigh...

 

[FDNewbie]

I'm the only one in the department who exclusively uses a Miller. And even during my Anesthesia rotation, I think I only came across one Anesthesiologist who was an exclusively Miller guy. The reason I've heard & found over & over is that a Mac is easier to use, especially given it's a larger blade, to it helps you get some good lift, and it's got a nice lip to help push the tongue out of the way. The Miller is very skinny & a lot smaller than the Mac, so you can't just jam everything outta the way; you gotta make sure you get a VERY good tongue sweep from the get-go (which can be challenging in some of the larger folk) or your view will be obstructed.

Having said that, I'd argue that the view you get with the Miller (both cuz you lift the epiglottis with it directly, and because it's a straight view, without a large rounded bulky Mac interfering with your line of sight in someone with a very small mouth opening etc) is superior by far.

Again, I use a Miller 2 exclusively on every adult patient (have only used a Miller 3 once I believe), and have always had at least a Grade 2 view (but almost always a Grade I view) after proper positioning etc, on every single patient. And I've only had to grab for a bougie once. That's my experience...

 

[Arcan57]

The main key is knowing what the short-comings of each blade are, and whether the other blade is going to fix that. Floppy epiglottis with Mac = switch to Miller. Bulky tongue with obstructed view = sweep aside with Mac. The bigger Mac blades can have issues with not being able to get the blade into the mouth because of the handle (sometimes you can insert the blade detached from the handle and the re-attach after some repositioning) or not being able to fit the tube into a small mouth.

 

[Groove]

(sometimes you can insert the blade detached from the handle and the re-attach after some repositioning)

Nice trick. I'll have to try that one...

 

[kungfufishing]

Mallampati may not be the the best to decide who is difficult to intubate, but it is a gauge that one can easily communicate over a discussion forum to give us a better sense of what the airway looks like pre-intubation instead of just describing a short neck and obese patient. I've seen some obese short-necked patients have Mallampati's of 1 that were easy intubations.

and didn't that feel great?

 

[Arch Guillotti]

I think a lot of that depends on how confident your faculty are, and your hospital protocol is (based on negative outcomes, politics, etc). I was just discussing this the other day, because I think it's sad that once there's difficulty intubating the patient, it's an immediate call to Anesthesia. Why don't you let the ED go through the (ED) difficult intubation pathway, and troubleshoot until you actually NEED help, vs. just defaulting to "oh we'll call Anesthesia now." Cuz if you're good, and you can't tube cuz you have no view etc, Anesthesia's gonna have the same trouble, and be doing the same thing you're doing; going down the pathway. We can do that too

This is the crux of the proverbial turf war between anesthesiology and the ED. I would be more than happy to never come down for another ED intubation in my life. However, if I am going to be there I want the airway. I do not want to deal with an airway after multiple repeated attempts have roiled the waters. The ED guys where I work are pretty good and we don't really get involved too much (for which I am thankful). But there have been a few rare instances over time where some cowboys bravado has caused a real mess. Everyone needs help sometime and should never let their pride get in the way, no matter who the help is coming from.

 

[deleted65604]

But there have been a few rare instances over time where some cowboys bravado has caused a real mess. Everyone needs help sometime and should never let their pride get in the way, no matter who the help is coming from.

Yes, cowboy bravado is bad. My colleague last month had to bail out an anesthesiologist who did rapid sequence intubation on a nightmare airway in the OR for an elective surgical procedure. My colleague got the tube where the anesthesiologist couldn't. Alas...the patient has severe anoxic brain injury.

 

[Arch Guillotti]

Yes, cowboy bravado is bad. My colleague last month had to bail out an anesthesiologist who did rapid sequence intubation on a nightmare airway in the OR for an elective surgical procedure. My colleague got the tube where the anesthesiologist couldn't. Alas...the patient has severe anoxic brain injury.

Are you serious?

I can't tell from your post.

The first step in the ASA difficult airway sequence is to call for help. I have called fellow anesthesiologists as well as ENT for help before, at times before attempts are even made to secure the airway if it truly looks horrendous. Not for elective cases but we not infrequently are involved in folks crumping in various ICU's usually.

 

[deleted65604]

Yes, I'm serious. The guy brady'ed down and went into PEA, when the nurses called the code. Bad anesthesiologist I guess.

 

[Arch Guillotti]

Yes, I'm serious. The guy brady'ed down and went into PEA, when the nurses called the code. Bad anesthesiologist I guess.

Cowboys are not unique to the ED.

 

[deleted109597]

Yeah. Usually the boots are the dead giveaway.

Wait....

 

[FDNewbie]

This is the crux of the proverbial turf war between anesthesiology and the ED. I would be more than happy to never come down for another ED intubation in my life. However, if I am going to be there I want the airway. I do not want to deal with an airway after multiple repeated attempts have roiled the waters. The ED guys where I work are pretty good and we don't really get involved too much (for which I am thankful). But there have been a few rare instances over time where some cowboys bravado has caused a real mess. Everyone needs help sometime and should never let their pride get in the way, no matter who the help is coming from.

I agree 100%. I've seen airways beat up to mush after multiple unsuccessful prehospital intubations, so I can imagine you've seen the same from the ED. It's hard, but we should all know when to stop and ask for help.

My comment was directed not so much as multiple attempts using the same thing (direct laryngoscopy), but for example, using a fiberoptic scope, an intubating LMA, a bougie, etc. Other airway aids & devices. Not so much a pride issue, but more of a very important learning pathway I think every ED doc should MASTER. Cuz what happens when said ED doc in podunk little ER gets someone they can't tube, and they're the only physician in-house? Go straight to cric? I sure as hell hope not, and I hope he's practiced going down the ED difficult intubation pathway quite a number of times.

The other thing I really wanted to comment on is the "However, if I am going to be there I want the airway" comment. I can defintiely appreciate that. But also please keep in mind that many times, Anesthesia isn't called cuz we actually NEED Anesthesia YET; it's more of "lets get 'em down here on standby, IN CASE we have trouble." When you come with the mindset of "if I'm down here, I'm doin the intubation," you're taking away the experience from a provider that you WANT to gain as much expertise as possible. A simple "ok lemme help you out" or even a "K I'll give you one attempt" would go along way for education (and kindness) without compromising the patient's condition. Thankfully I don't have this issue cuz all the Anesthesiologists know me well and trust me, but this is the most common complaint I hear from other residents (when Anesthesia shows up, even as backup, they simply take over). Something to keep in mind...

 

[Arch Guillotti]

Unfortunately, hence the eternal pissing match between specialties. As I have said before, the ED where I work handles their business the VAST majority of the time. I don't even mind letting anybody in the ED "take a look" while I am there. What I do resent is cowboys who refuse help even when it is there.

Even if I am in a quasi-stable scenario with potential for serious badness, I do not hesitate to call for help. I don't let my pride get in the way either.

The other thing I really wanted to comment on is the "However, if I am going to be there I want the airway" comment. I can defintiely appreciate that. But also please keep in mind that many times, Anesthesia isn't called cuz we actually NEED Anesthesia YET; it's more of "lets get 'em down here on standby, IN CASE we have trouble." When you come with the mindset of "if I'm down here, I'm doin the intubation," you're taking away the experience from a provider that you WANT to gain as much expertise as possible. A simple "ok lemme help you out" or even a "K I'll give you one attempt" would go along way for education (and kindness) without compromising the patient's condition. Thankfully I don't have this issue cuz all the Anesthesiologists know me well and trust me, but this is the most common complaint I hear from other residents (when Anesthesia shows up, even as backup, they simply take over). Something to keep in mind...

 

[FDNewbie]

Unfortunately, hence the eternal pissing match between specialties. As I have said before, the ED where I work handles their business the VAST majority of the time. I don't even mind letting anybody in the ED "take a look" while I am there. What I do resent is cowboys who refuse help even when it is there.

Even if I am in a quasi-stable scenario with potential for serious badness, I do not hesitate to call for help. I don't let my pride get in the way either.

I hear ya loud & clear

 

[crewmaster1]

I understand you operate under very different constraints in the ED. A few minutes is all you need for an awake intubation although I doubt any ED residencies are teaching this.

I hope all EM residencies are teaching this. We did awake intubations all the time for indicated patients. Ketamine sedation, topical anesthesia, etc. Usually fiberoptic or william's airways or even awake DL. This seems like normal airway stuff that any recent EM grad should be comfortable with. I also enjoyed all the comments from the Cincinnati anesthesiologist who ran down to rescue the EM doc at UC. I just finished 4 years of residency there and have seen one intubation by anesthesia in the ER. EM does all tubes (trauma, medical, whatever). We have better airway equiptment in our simulation lab than they do in their OR! Anesthesia may know a lot about airways, but they sure aren't around 24/7 in most hospitals and last time I checked most patients with airway emergencies can't wait for anesthesia to drive in. EM docs need to be proficient in emergent airway management and training in a program where anesthesia comes into the ED for a bunch of airways is crap.

 

[Arch Guillotti]

More power to you. I think all ED programs should teach awake intubation. If you do it right you don't even need to give sedation.

I hope all EM residencies are teaching this. We did awake intubations all the time for indicated patients. Ketamine sedation, topical anesthesia, etc. Usually fiberoptic or william's airways or even awake DL. This seems like normal airway stuff that any recent EM grad should be comfortable with. I also enjoyed all the comments from the Cincinnati anesthesiologist who ran down to rescue the EM doc at UC. I just finished 4 years of residency there and have seen one intubation by anesthesia in the ER. EM does all tubes (trauma, medical, whatever). We have better airway equiptment in our simulation lab than they do in their OR! Anesthesia may know a lot about airways, but they sure aren't around 24/7 in most hospitals and last time I checked most patients with airway emergencies can't wait for anesthesia to drive in. EM docs need to be proficient in emergent airway management and training in a program where anesthesia comes into the ED for a bunch of airways is crap.

 

[Hamhock]

More power to you. I think all ED programs should teach awake intubation. If you do it right you don't even need to give sedation.

Agree with Arch and the crewmaster.

[Although I think many of the ED awake intubations - even if performed perfectly - require sedation (usually ketamine), as there is insufficient time.]

Note to medical students who are applying for EM spots:

Quit wasting time looking for the "Top 10" EM residencies (the best is clearly In-n-Out, which I just enjoyed twice this weekend) or the program with the best international opportunities. Look for programs where you will have the opportunity to master emergency medicine...programs that include things like awake intubation.

I have said it before - and, although it is unpopular - I will say it again because it is accurate: Not all EM residencies are created equal. Not all EM residencies will train you sufficiently (as much as we all like to think so). Billy Mallon and crewmaster are right: There are huge differences in training.

HH