Category Archives: Anesthesia

The MAC Blade, The Vallecula, and the Hyoepiglottic Ligament

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Correct placement of the tip of the MacIntosh , or MAC, blade is critical to successful intubation. When learning to intubate, novice intubators often prefer the MAC blade because:

  • curved shape makes it easier to insert under the upper teeth,
  • wide area makes it easier to balance the head on the blade during the lift,
  • easier to control the tongue with the side flange.

However, if you don’t have the tip of the blade positioned properly in the vallecula, you wil not lift the epiglottis and you will have a poorly view of the larynx. Why is this?

How The MacIntosh (MAC) Blade Works

A quick review of the anatomy is warranted. The vallecula is the mucosa covered dip between the back of the tongue and the epiglottis. The hyoepiglottic ligament runs under the vallecular mucosa and connects the hyoid bone to the back of the epiglottis.

Illustration showing the hyoepiglottic ligament running in the vallecula to connect the hyoid bone with the epiglottis

The hyoepiglttic ligament connects the hyoid bone to the back of the epiglottis

Lateral Xray clearly showing the hyoid bone, the epiglottis and the vallecula connecting them

Lateral Xray clearly showing the hyoid bone, the epiglottis and the vallecula connecting them

The curved MAC blade is designed to match the curve of the tongue and to put point pressure on the hyoepiglottic ligament. With pressure in the vallecula on this ligament, the epiglottis is pulled upward. The curved blade can then pull the tongue and soft tissue under the tongue forward, bringing the glottis into view.

The tip of the curved blade presses on the vallecula, allowing you to lift the epiglottis by pulling on the folds at its base. The glottis is revealed with the epiglottis hanging above it.

The tip of the curved blade presses on the vallecula, allowing you to lift the epiglottis by pulling on the folds at its base. The glottis is revealed with the epiglottis hanging above it.

In this video, posted on YouTube by AIMEairway.ca, you can see that if you lift too early, when the blade is not placed far enough into the vallecula to engage the ligament, then pressure from the blade tip does not lift the epiglottis. Advancing a little farther, placing the tip in the vallecula does lift the epiglottis.

If you advance the blade tip too far into the vallecula, it will press on the base of the vallecula and force the epiglottis down, obscuring your view of the glottis. The difference between lifting too early or too late (by placing the blade tip too shallow and too deep respectively) can be just a mm or two.

Size of the MAC Blade matters

MAC blades come in different sizes to match your patient. However, you must choose the correct size to apply th­­­e correct point pressure on the hyoepiglottic ligament. The correct size blade must be long enough to reach into the vallecula. You can estimate the correct size by holding the blade adjacent to the patient’s lower jaw and measuring it against the projected location of the vallecula.

Illustration showing how to estimate the size of a laryngoscope blade for intubating an infant or young child

Laryngoscope blades come in different sizes and you should choose the optimal size if you can.

Blade Too Short

If the blade is so short that it doesn’t reach the vallecula, then lifting the blade will not lift the epiglottis (see video above). Indeed may fold it downward over the glottis.

Blade Too Long

On the other hand, you can use a longer MAC blade. The key to success with a longer blade is to avoid inserting the blade too deep, and covering the larynx. You must restrain yourself and insert only to a depth sufficient to place the blade tip in the vallecula. You will know if you have placed the blade too deep because the larynx will be hidden under the blade.

Photo of view during laryngoscopy, on the left the esophagus is seen "tented" to appear like the larynx, on the right the larynx.

If you insert your blade too deep you will hide the larynx underneath, as on the left. This action also tents the esophagus and can made it mimic the glottic opening if you are not careful.

When using a longer blade in a small patient, you will find that you will have a fair amount of blade outside the mouth. In this case you must be especially careful to avoid lips and teeth.

Altering the Angle Of The MAC Blade To Optimize View

As you can imagine from the above anatomical relationships, a very small change in angle at the handle will markedly alter the angle, location and point pressure of the tip. Any angulation of the blade must be done carefully to avoid damaging the teeth.

Insertion: Always Protect Those Lips and Teeth

Insertion of the blade should always be delicate and deliberate With the mouth open as wide as you can, insert the blade slightly to the right of the tongue. Don’t hit the teeth as you insert. If necessary, you can tilt the top of the handle slightly to insert the blade into the mouth, then rotate the blade back, scooping it around the right side of the tongue as you do so.

Avoid catching the lips between the blade and the teeth. I use my right index finger to sweep the lips out of the way of the blade as I insert it. You may need to angle a curved blade slightly to pass the teeth and then return the blade to a more neutral position once it has entered the mouth.

How To Know You’re In The Vallecula

With experience, you will develop good instincts on how deep to insert the blade. Always look for the tip of the epiglottis as you insert the blade. Once you see it, continue to advance the blade — usually close to its maximum depth if it’s the correct size. Simultaneously sweep the tongue to the left as you advance. Once you see the full epiglottis you can now start to transfer the weight of the patient’s head onto the blade as you lift. Again, watch for the lips. Leave your blade toward the left side of the mouth with the tongue pushed out of the way. Continue to advance until

As you lift, the pressure from the tip should lift the epiglottis. If it doesn’t, carefully slide the tip a little deeper into the vallecula to engage the ligament and try again.

The list of posts below leads to other articles on intubation technique.

May The Force Be With You

Christine E Whitten MD

Author of Anyone Can Intubate— a Step By Step Guide
and
Pediatric Airway Management— a Step By Step Guide

LINKS TO PRIOR DISCUSSIONS WITH MORE DETAILS OF HOW TO INTUBATE:

 

Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten

Please click my book covers to preview on amazon.com

Learning Intubation: Head Position Effects Laryngeal View

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When first learning intubation,  a beginner often concentrates on memorizing the key laryngeal anatomy. This is important of course. If you can’t recognize the vocal cords, you will not be able to successfully intubate. However, even more important to learning intubation is understanding how the larynx relates to the other structures in the head and neck. In order to intubate you must manipulate those other structures to bring the larynx into view.

A prior post, When Learning Intubation Is Hard, described in detail some of the most common barriers to learning to intubate. Here I will concentrate on helping you see how head position effects your ability to see the larynx.

Larynx Location In The Neck

To feel your own larynx, place your hand on the front of your neck, with thumb and forefinger on either side of the firm, roughly cylindrical shape in the midline.

Illustration showing Relationships thyroid and cricoid cartilage to cricothyroid membrane

Relationships thyroid and cricoid cartilage to cricothyroid membrane

The adult larynx lies opposite the 5th, 6th cervical vertebrae, as opposed to the infant larynx that lies opposite the 2nd, 3rd and 4th. The fact that the infant larynx is higher in the neck leads to greater risk of airway obstruction and a need to slightly alter technique during pediatric intubation. A link to how to intubate the pediatric patient is located at the end of this article. Here we will concentrate on the adult.

The larynx is located in front of the esophagus in the neck. The opening to the larynx, called the glottis, and the opening to the esophagus are immediately adjacent to each other. Misidentification of the esophagus as the glottic can lead to esophageal intubation.

Illustration showing how easy it is to insert a laryngoscope blade too deeply and hide the larynx during intubation of an infant or small child

It’s very easy  to insert the laryngoscope blade too deep, as in the right picture. If too deep you will not see recognizable anatomy because you are looking down the esophagus and hiding the larynx.

 

Photo of view during laryngoscopy, on the left the esophagus is seen "tented" to appear like the larynx, on the right the larynx.

If you insert your blade too deep you will hide the larynx underneath. This action also tents the esophagus and can made it mimic the glottic opening if you are not careful.

How The Larynx Relates To Other Structures

Look at this lateral Xray  of a head in neutral position. The outline of the epiglottis, the hyoid bone, the thyroid cartilage and the cricoid cartilage are easily identified. Notice the relationship of the larynx to the esophagus. The larynx lies in front of the esophagus but the opening to the larynx (the glottis) and the esophagus are right next to each other. Accidental esophageal intubation is a risk with every intubation.

Lateral view Xray showing the distinct outlines of the parts of the larynx and their relationship to the jaw, tongue and cervical spine.

Lateral view Xray showing the distinct outlines of the parts of the larynx and their relationship to the jaw, tongue and cervical spine.

Now imagine yourself intubating this patient. what would you have to do to bring the larynx into view? How deep would you have to insert a Macintosh blade to  place the tip in the vallecula? How deep would you need to insert a Miller blade to lift the epiglottis?

Here is a CT scan of another adult patient. Notice that in this second patient the larynx is located higher in the neck.

Normal CT side view showing relationship of laryngeal structures to external anatomy

Normal CT side view showing relationship of laryngeal structures to external anatomy

Whereas the epiglottis in the first patient is low behind the tongue, this patient’s epiglottis is higher. The depth of insertion and the strategy to lift the epiglottis will change from patient to patient. Straight blades often work better in patients with a larynx higher in he neck and this may be one of those patients.

How Does Neck Position Affect The Larynx During Intubation

Let’s look at a lateral Xray of our first patient, but now with his head tilted all the way back in full extension. Patients with respiratory distress, will often tilt their heads back. You can see that this position more fully opens the airway and decreases resistance to breathing.

lateral Xray of the neck in full extension showing how the relationship of the larynx changes with respect to the rest of the neck structures. Extension without placing the patient in the sniffing position will hide the larynx behind the tongue, or a so-called anterior larynx.

Lateral Xray of the neck in full extension showing how the relationship of the larynx changes with respect to the rest of the neck structures. Extension without placing the patient in the sniffing position will hide the larynx behind the tongue, or a so-called anterior larynx.

During intubation, we need to tilt the head back to bring the axis of the oral and pharyngeal axes into alignment. But if the patient is not in a good sniffing position,  with the head moved slightly forward  in addition to being tilted, the larynx may remain hidden behind the tongue during laryngoscopy.

Let me rotate this image to show you what I mean.

Lateral neck Xray showing how extreme head extension, without the sniffing position, can make visualization of the larynx difficult.

Lateral neck Xray showing how extreme head extension, without the sniffing position, can make visualization of the larynx difficult.

You can now see how anterior that larynx would look during laryngoscopy. Pushing down on the cricoid cartilage might help rescue a difficult intubation in a situation like this, but optimal head and neck positioning from the beginning would work better.

When getting ready to intubate, always glance at the side of your patient and assess whether the head and neck are in an optimal position before you start. If it’s not optimal, try to fix it. That several seconds can save you, and your patient, potential trauma.

Head Position Also Affects Laryngeal Opening

As long as we are looking at X-rays, let’s look at our first patient with his head flexed fully forward. When the head is flexed forward, the structures in the posterior pharynx and the tongue tend to obstruct the airway. You can test this by flexing your head forward as far onto your chest as you can. It becomes much harder to take a breath.

lateral Xray showing that With the head flexed fully forward onto the chest, the airway is almost fully obstructed. Visualization of the larynx wold be impossible.

With the head flexed fully forward onto the chest, the airway is almost fully obstructed. Visualization of the larynx would be impossible.

While no one would position a patient’s head this way for intubation, it’s common for novices to place too many pillows under the head trying to obtain a good sniffing position. If the head is too high, the patient, and the intubator, will not be able to tilt the head back.  In other words, our novice intubator, trying to maximize sniffing position, sabotages himself. Again, prior to intubation take a look to the side of your patient. Try to tilt the head back (or have the patient tilt their head back).

When learning to intubate, learn the anatomical relationships, not just laryngeal anatomy.  A good intubator understands that knowledge of how those structures move in relationship to each other gives you the power to manipulate that anatomy to give you the best possible view during intubation.

Please share with your fellow students. I’ve included a list with links below to previous posts on learning intubation to help you perfect your skills. Feel free to ask questions. Let me know if there are any topics that you would find helpful.

May The Force Be with You

Christine Whitten MD, author
Anyone Can Intubate, A Step By Step Guide
and
Pediatric Airway Management, A Step By Step guide

LINKS TO PRIOR DISCUSSIONS WITH MORE DETAILS OF HOW TO INTUBATE:

 

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten  Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

Please click on the covers to preview my books at amazon.com

Announcing My Latest Article Has Been Published: “10 Rules for Approaching Difficult Intubation”

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I’m excited. My latest article, titled, “10 Rules for Approaching Difficult Intubation,
Always Prepare for Failure” has just been released in the journal supplement Airway Management, published by Anesthesiology News.

Managing the difficult airway is one of the most challenging, risk ridden, and downright scary clinical problems in anesthesia. The article makes the point that although we all know that a “can’t intubate, can’t ventilate” scenario can happen to anyone at anytime, many of us practice as though it will never happen to us. We must always prepare for failure. In the article, I’ve provided practical information from my 38 years of experience on how to recognize, manage, and protect our patients with challenging airways.

While there is a lot of information for the novice, there are also clinical pearls for the experienced intubator. I’m hoping you will find this information helpful to you, and to your trainees.

You can find the article on-line here, where you can also download a pdf version to share:

https://www.anesthesiologynews.com/Review-Articles/Article/08-18/10-Rules-for-Approaching-Difficult-Intubation/52456

In addition to my article, please read the others as well. This issue is full of helpful, well written submissions. I have always found Anesthesiology News to provide interesting and timely updates and well written reviews, and this issue is no exception.

May The Force Be With You

Christine E. Whitten MD. author
Anyone Can Intubate, A Step By Step Guide
and
Pediatric Airway Management, A Step By Step guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten     Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

Please preview my books at amazon.com by clicking on the covers.

 

Bilateral Tension Pneumothorax: Harder To Diagnose

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Tension pneumothorax is a life-threatening emergency. We all know the signs of tension pneumothorax:

  • unilateral breath sounds (breath sounds absent on affected side),
  • thorax may be hyperresonant,
  • jugular venous distention,
  • tracheal deviation to the opposite side,
  • maximum heart sounds shifted to the opposite side, and often
  • tachycardia
  • hypotension

However diagnosis is more difficult if the patient is suffering from bilateral tension pneumothoraces. We think about bilateral tension pneumothorax occurring with trauma cases. Yet the three cases I’ve seen in my career were complications of intubation and emergency airway management. Continue reading →

PostObstructive Pulmonary Edema

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Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction.  It can be mild or severe. My first experience with it was in 1983.

The Case

In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated blood pressure cuffs. The patient was a healthy 6’3” tall and 250 lbs , 20 year old man. All muscle and clearly in great shape. He had just had knee surgery under general anesthesia and was on the verge of waking up.

He was coughing vigorously on the endotracheal tube. Four people held him down. My resident, fearful he night hurt himself or the team, extubated him while he was still coughing and before he was following commands. Unfortunately the patient was still in stage 2, when the airway reflexes are hyperdynamic.

Within seconds the patient went into laryngospasm, intense spasmodic closure of the vocal cords and other laryngeal muscles. There followed several minutes of struggling to re-establish an open airway. Finally the spasm broke with the use of positive pressure and the patient awoke.

However the mood in the room quickly turned from relief to concern. Our patient started to panic, claiming that he couldn’t breathe. His color was poor. He was wheezing badly, with pink frothy sputum bubbling out of his mouth. He was awake enough to communicate with us but so panicked that he started to fight the team of caregivers. Continue reading →

Anatomic Dead Space Affects Hypoventilation

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Understanding anatomic dead space is important to recognizing subtle hypoventilation. Hypoventilation from sedation, pain medications, anesthesia in the immediate postoperative period is common. The most obvious sign is slowing of the rate of breathing. A more subtle sign is that tidal volume becomes shallower. Having a tidal volume close to, or smaller than the patient’s dead space can lead to significant hypercarbia, hypoxia, and respiratory failure. This article discusses the concept of dead space and it’s clinical use in recognizing hypoventilation and preventing hypoxia and hypercarbia. Continue reading →

GlideScope Technique For Intubation In Small Mouths

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The GlideScope Video Laryngoscope (GVL) is an extremely useful tool for managing challenging intubations, but it can be more difficult to use if your patient has a small mouth and a high arched, narrow palate. The problem: once the GlideScope is in place in a small mouth, maneuvering the endotracheal tube around it and into the posterior pharynx can be challenging. If you can pass the endotracheal tube (ETT) at all, the cuff tends to scrape against the teeth, risking rupture. However, there is a modified GlideScope technique you can use in those situations. Continue reading →

Difficult Intubation In A Newborn

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Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. Continue reading →

NITROUS OXIDE: SHOULD WE USE IT?

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When I was training, we used nitrous oxide on just about every anesthetic. It was easy to use. It was inexpensive. It didn’t tend to effect hemodynamics so it was useful in less stable patients when combined with an opioid. It helped speed induction through the second gas effect. It was not metabolized so renal and liver insufficiency were of less concern.

However, with all of the more recent investigation into reasons for cognitive dysfunction or decline in infants and the elderly following anesthesia, a lot more is now known about the pharmacologic disadvantages of nitrous oxide (1, 2, 3). Continue reading →

Intubation During Cardiac Resuscitation

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Intubation during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.

Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.

Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.

Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.  Continue reading →

When Learning Intubation Is Hard

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Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the intubation technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals.

I believe there are 4 chief barriers that inhibit learning how to intubate:

  1. Failure to visualize how the outside anatomy links with the inside anatomy makes it hard to predict how deeply to insert the blade.
  2. A mistaken belief that placing the laryngoscope blade itself is all that is needed to align the axes of the airway and reveal the larynx.
  3. Failure to grasp the dynamic nature of the larynx, and the need to actively manipulate it during intubation.
  4. A lack of understanding that intubation is not a sequence of isolated steps, but is instead a complex dance of interacting steps, each setting the stage for the next.

This discussion is going to assume some knowledge of the basic intubation technique. If you’d like to review those basics you can find links for multiple prior in depth discussions at the end of this article. (Illustrations and animation from Anyone Can Intubate, 5th edition, C Whitten MD.) Continue reading →

Communication In A Crisis: A Case of Respiratory Depression In A Child:

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When I’m teaching communication in a crisis to my Perioperative/OR nurses, I often recount the story of what happened during one particular child’s recovery years ago. This case, involving a 2 year old child who developed respiratory depression in the recovery room, demonstrates how good communication in a crisis, including the ability to challenge an authority figure, can improve patient safety and allow collaborative teamwork in a crisis management situation. Continue reading →

Airway Emergency: Start With The Basics of Airway Management

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We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition. Continue reading →

Close Call In Honduras With A Nosebleed

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I recently visited Honduras with a Head and Neck surgical team where we had a close call with a potential airway obstruction due to a blood clot. The case illustrates how a provider should never make assumptions, because if those assumptions are wrong, you can endanger your patient.

After a long day in the OR, while we were packing up to leave, a nurse from the ward ran in and said that one of the patient’s who had had a septoplasty that day for chronic sinusitis was bleeding. I immediately started setting up the OR again while our surgeon went over to the ward. Continue reading →

Finding PEEP In a Bottle (of Water): Thinking Outside The Box

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As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.

Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.

Let me give you an example of one rather exciting case from early in my volunteer experience. Continue reading →

MacGyvering In Anesthesia

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I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day.  The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.

As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as reassembling an anesthesia machine that fell apart right after intubation (see this story here) or improvising PEEP from some suction tubing and a bottle of water. (see that story here)

But being able to improvise is just as important in the settings of the more modern hospital. Continue reading →

Hair Style Can Impact Intubation

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Healing Little Heroes director dressed as Darth Vader at Ronald McDonald House, San Diego

Our Healing Little HeroesFoundation  founder dressed as Darth Vader at Ronald McDonald House, San Diego

Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.

On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. There is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Continue reading →

Intubation With Airway Bleeding and Massive Emesis

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During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse airway bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? Here I describe two cases, one involving blood and the other massive emesis, that required intubation through a large puddle of fluid. I offer tips and tricks to assist you in your future emergency management. Continue reading →

Avoiding Pediatric Drug Errors

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Pediatric drug errors are unfortunately common. The literature states that medication errors occur in 5% to 27% of all pediatric medication orders, a very sobering number. Considering that many of these errors occur in the smallest, and therefore most vulnerable, of our little patients, the potential impact is especially great.

For the last 3 months, I’ve been teaching critical event training classes for our OR and Perioperative RNs, Anesthesia MDs and CRNAs, and OR techs in preparation for opening our new hospital in San Diego. Several of the scenarios involved pediatric cases. As part of that process, I’ve been reviewing with my providers ways to avoid the potentially deadly problem of pediatric drug dosing errors as well as ways to avoid them. Let’s discuss some of the ways to make pediatric medication administration safer. Continue reading →

Difference in Manual Ventilation: Self-Inflating Ventilation Bag vs. a Free Flow Inflating Bag

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Manual ventilation with a bag-valve-mask device requires a good mask seal against the face in order to generate the pressure to inflate the lungs. But it also requires knowledge of how to effectively use the ventilation device to deliver a breath. This article will discuss the differences in ventilation technique for self-inflating vs free-flow ventilation bags. Understanding those differences is important for successful manual ventilation of your patient. Continue reading →