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!
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.
Insert an Oropharyngeal airway (OPA)
Insert an Nasopharyngeal airway (NPA)
Suction if you need to…
Open the airway and ventilate via a bag-valve-mask using high-flow oxygen.
Bag Valve Mask BVM
Reuben Strayer’s take on bag-valve-mask ventilation is essential viewing:
Emergency BVM Ventilation
If the patient is edentulous, then you might want to adjust the position of the mask
Edentulous mask position
- Racine SX, et al (2010). Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement. Anesthesiology, 112 (5), 1190-3 PMID: 20395823
Don’t forget you don’t need to hand ventilate if you’ve got a ventilator handy…
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.
Steps of laryngoscopy
Remember to use bimanual laryngoscopy.
Make sure you can tell the difference between the larynx and the esophagus!
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:
Arcuate stylet vs Straight cuff
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:
Advanced bougie (McGill)
Laryngeal mask airway (LMA)
Still can’t get the tube in? Reach for an 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:
Rapid Sequence Airway (RSA) (Braude)
You can intubate through a standard LMA, but it is usually easier to use a dedicated intubating LMA:
The Intubating LMA (HQMedEd)
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
Percutaneous needle cricothrotomy (Heard)
This how to convert the cannula into a definitive airway using the Melker kit:
The Melker kit
Instead of the needle you might want to use a knife:
Open cricothyroidotomy a la Scott Weingart
Or the bougie-assisted approach shown by the HQMedEd team:
Or you might like this scalpel-bougie-tube only approach from Andy Heard at Royal Perth Hospital (I know I do!):
Scalpel-bougie-tube only approach (Heard)
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.
Some cric kits are so quick and easy they don’t even need commentary!
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:
Video laryngoscope (VL)
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
Awake intubation in the ED (Weingart)
And don’t forget Dr Michael Baillin’s entertaining demonstration of “auto” awake fiberoptic intubation:
Awake Fiberoptic intubation (Baillin)
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.
Advanced airway management of r Emergency Physicians
But wait, there’s an encore — Reuben also has a great 12 minute screencast on pediatric intubation:
Pediatric airway for emergency physicians
Additional Airway Management Resources:
- The free videos on the TheAirwaySite.com and Richard Levitan’s absolutely mind-blowingly awesome AirwayCam site.
- Richard Levitan gave a MUST SEE talk at Mount Sinai School of Medicine in 2012 called “Anatomic Insights and Practice Changing Concepts” that has been reproduced as EMCrit Podcast 70 – Airway Management with Rich Levitan.
- Airway Management Academy [via @AirwayMxAcademy]
- Airway Management Academy Media Library [via @AirwayMxAcademy]
- Essential Emergency Airway Care Course (EEACC) [via @TheSharpEndCrew]
- For the novice there is also the great EMBasic Airway Episode podcast by Steve Carroll.
Resus Room Reflection
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.