Ok Team Airway,
Here is lecture #4. We will go over a few "best practice" techniques that can allow for "best look" laryngoscopy. In addition to maximizing your first pass success by adequately preoxygenating your patient, employing nasal apneic oxygenation, properly positioning your patient, having the psychomotor skills of a proficient laryngoscopist is very useful.
The most important thing is PRACTICE, PRACTICE, and PRACTICE.
Practice inside your mind, practice on plastic, and "practice" on patients.
In order to make your practice most useful, you must gain the necessary theoretical knowledge and get the required experience.
In addition to proper preparation, dividing the actual laryngoscopy into three separate steps: visualizing the epiglottis, then visualizing glottis, and then finally passing the tube, can be very helpful. Also, using a bougie, together with proper external laryngeal manipulation, can maximize your change for first pass success.
Anyway, of could I'm not going to be able to teach anyone how to work a laryngoscope with a 15 minute talk, but here are a couple of pointers.
Pretest #1: Laryngoscopy
- During RSI, describe the sequence of steps that reduces the chances of desaturation during the preoxygenation, apneic, and the intubation periods.
- What does the airway mnemonic “LEMON” describe? Describe what the letters stand for:
- While preparing for intubation where should the rigid suction be located?
- When should laryngoscopy and attempted tube passage be stopped and alternate methods of oxygenation (BMV or LMA) be attempted?
- Describe three types of External Laryngeal Manipulation (ELM). Compare “Bimanual Laryngoscopy” and it to the “BURP maneuver” and Cricoid pressure.
- Describe, draw, and label the relevant airway anatomy that you will see as you advance the laryngoscope blade
- Describe the best way to hold a laryngoscope
- Describe how the laryngoscope be inserted in order to best pass the tube? Review the anatomic landmarks that should be vocalized see as you advance.
- What are the advantages/disadvantage of using the bougie or an ET tube with a stylet for all intubations?
- Describe the ideal, “straight to cuff” or “hockey stick” shape of a stylet’ed ETT used in direct laryngoscopy?
- Describe how to use a bougie during laryngoscopy?
- What type of providers do not need to use a bougie or stylet in ED intubations?
- Which methods are adequate to verify tube placement in the trachea and exclude unintentional esophageal intubation?
- Describe how to best use the ETCO2 monitor to confirm ETT placement
- How long does our side-stream ETCO2 detector take to warm up?
- Describe or draw a reasonable difficult airway algorithm.
---for full clarity: click through to watch in Vimeo
Here is paper on the difficulties of predicting difficult airway in the ED
The master (Richard Levitan) himself explaining the importance of dividing Intubation into 3 steps: Epiglottoscopy, visualizing the glottis, and tube passage. (http://www.airwaycam.com/)
Here is another explanation of "best look" laryngoscopy by Prof. George Kovacs. Good stuff.
Some great Bougie Tips: http://hqmeded.com/the-bougie-2/
An example of ELM from AirwayCam
The Pro-Con Cricoid Debate at SMACC GOLD 2014:
5 Minutes of great tips on the bougie
Use a Airway Checklist before every emergent ED intubation:
Complete a Registry Form after EVERY ED intubation:
Here is some great pictures to allow you to see some of the anatomy