Own the Airway!

aka Ruling the Resus Room 007

This is a collection of my favourite online video resources to help even the greenest emergentologist ‘own the airway‘. This post contains some truly awesome educational resources. Enjoy!

Preoxygenation

First, buy yourself some time by adequately preoxygenating the patient.

• Check out the LITFL ‘Own the Oxygen!’ guide
• EMCrit.org has a great page of resources on  preoxygenation, reoxygenation and deoxygenation. The Scott Weingart approach to ‘delayed sequence intubation’ is described in Emcrit Podcast 40.

Open and clear the airway

I’ll start off with the basics. Make sure you can use simple airway adjuncts, including the oropharyngeal and nasopharyngeal airways.

Ventilation

Open the airway and ventilate via a bag-valve-mask using high-flow oxygen.

Reuben Strayer’s take on bag-valve-mask ventilation is essential viewing:

If the patient is edentulous, then you might want to adjust the position of the mask

Don’t forget you don’t need to hand ventilate if you’ve got a ventilator handy…

Laryngoscopy

Now let’s get Scott to talk us through the steps of laryngoscopy. Optimise the position of the patient before you start — this step is often overlooked in the emergency setting. Take Scott’s advice on making the patient’s earhole the same height as the jugular notch to heart.

Stylets and bougies

Bend your stylet to the correct shape. This video shows why it is easier if the stylet is ‘straight-to-the-cuff’, with a hockey stick bend near the cuff. Remember to insert the endotracheal tube from the right side of the patient’s mouth to maximise your view and provide optimal control of the position of the tip of the endotracheal tube:

If you can’t get the tube in first time you might want to recheck the patient’s positioning and consider reaching for a bougie. The bougie should be your best friend in the emergency department!

The new video takes bougie trouble shooting to a whole new dimension of sophistication:

Laryngeal mask airway (LMA)

You can also use an LMA as part of a “Rapid Sequence Airway” (RSA) approach to improve peri-intubation oxygenation before laryngoscopy like Darren Braude does:

You can intubate through a standard LMA, but it is usually easier to use a dedicated intubating LMA:

Needle cricothrotomy

OK… you’ve tried an LMA but the chest ain’t rising and the patient looks a little blue… Great, now you can’t intubate and can’t ventilate. While you wait for help to arrive, your options include percutaneous needle cricothrotomy as demonstrated by Andrew Heard – https://www.youtube.com/watch?v=Pzf29LT6VJQ

This how to convert the cannula into a definitive airway using the Melker kit:

Surgical cricothrotomy

Instead of the needle you might want to use a knife:

Or you might like this scalpel-bougie-tube only approach from Andy Heard at Royal Perth Hospital (I know I do!):

Scott Weingart and Minh Le Cong have a great discussion of the merits of the needle cric vs an open bougie-assisted approach in EMCrit’s Podcast 053 — Needle vs Knife: Part 1. There is also this video of Ernest Wang’s approach to the emergency cricothyrotomy.

Laryngoscope doesn’t work!

But, what if all the laryngoscopes in the hospital aren’t working?  You could resort to the old spoon and torch technique I’ve described previously, or my personal favourite ‘blind digital intubation’:

• Rich JM. Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proc (Bayl Univ Med Cent). 2008 Oct;21(4):397-9. PMCID: PMC2566913

Here is how Rich describes the technique:

Bougie-assisted digital intubation. (a) After the epiglottis is identified by palpating it with the long finger of the left hand, the bougie is threaded through the glottis and advanced into the trachea. Tracheal clicking elicits tactile vibrations, which confirm tracheal placement of the bougie. (b) The bougie is withdrawn slightly so that the 25-cm mark is at the corner of the lip. The endotracheal tube is threaded over the bougie while the bougie is stabilized in place. (c) With the bougie held in place, the endotracheal tube is turned a quarter turn to the left and then advanced to an appropriate depth. (d) The tube is held in place while the bougie is withdrawn. Tracheal intubation is then confirmed using capnography or an esophageal detector device. PMC2566913

…Or why not just cheat and use the Pentax video laryngoscope they’ve got in my old department:

Awake intubation

There is a way to avoid all this ‘can’t intubate, can’t ventilate’ messiness of course. If the patient isn’t crashing, but needs intubation and you think it might be difficult, then awake intubation of the a spontaneously breathing patient is the way to go. First up is Scott Weingart’s demonstration

And don’t forget Dr Michael Baillin’s entertaining demonstration of “auto” awake fiberoptic intubation:

Reuben Strayer puts it all together!

To finish, Reuben Strayer, from Emergency Medicine Updates, brings it all together in his screencast lecture on Advanced Airway Management for the Emergency Physician. Also, check out his Emergency Department Intubation Checklist.

But wait, there’s an encore — Reuben also has a great 12 minute screencast on pediatric intubation: