Intubation During Cardiac Resuscitation

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

Hair Style Can Impact Intubation

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

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

Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

When I was training, awake intubation for anticipated difficult airway was routine. Blind nasal intubation and fiberoptic intubation were common events. The advent of video laryngospcopy  has made the need for awake intubation much less common. Instruments like the Glidescope and the McGrath video laryngoscope have revolutionized intubation, and made the difficult intubation scenario fortunately much more uncommon.

However, awake intubation with the patient breathing spontaneously is still sometimes optimal for patient safety.  Awake intubation can be performed using standard laryngoscopy techniques, but it is more commonly done using specialty intubation techniques such as blind nasal or fiberoptic intubation.

Many providers are uncomfortable with performing awake intubations and leave it as a last resort. There are a variety of reasons for this discomfort, including lack of experience and/or the fear that the patient will remember the intubation and think poorly of their care. However, awake intubation can be a safe and comfortable strategy in many clinical situations and all providers should develop expertise with one or more techniques of choice — before an emergency forces them to use one.

This article will discuss how to decide when to do an awake intubation. Future articles will discuss how to do them. Continue reading

Avoiding Difficult Intubation Of The Easy Airway

It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. We’ve all done it. Let’s see how to avoid this pitfall. (All illustrations by Christine Whitten MD, Anyone Can Intubate). Continue reading

Positioning The Head For Intubation

Positioning the head and neck for intubation in the sniffing position can make intubation easy, or extremely hard. Many years ago our operating room administration decided that the bath towels we were using to position the head for intubation were a potential danger for shedding lint. So one night, in their infinite wisdom, the towels were all summarily confiscated and when we arrived the next morning there wasn’t a single towel to be found, ever again. It may be an exaggeration to say that chaos ensued, but it felt like that.

The reason this event is so memorable is that for the next several days our anesthesia providers had trouble intubating. We likened it to an expert golfer who, when suddenly faced with a new set of golf clubs of slightly different weight and length, suddenly has to relearn the game. It made us realize that how we position the head in the sniffing position often sets us up for either an easy or for a more difficult intubation if you don’t realize what’s happening during the positioning. Continue reading

Awake Intubation With The GlideScope

Awake intubation with the GlideScope can be an especially helpful technique when intubation of a difficult airway under direct vision is optimal. One of the most challenging scenarios to face is a tumor in the airway. Working closely with your surgeon is important. In this particular case, we actually had a video available of what this 8 mm airway polyp looked like popping in and out of a laryngeal opening of about the same size with each breath like a potential cork. According to the surgeon our patient had come to the clinic because she had been experiencing some increased shortness of breath. Having the video was a rare advantage. Follow this link to youtube video showing pedunculated vocal cord polyp obstructing the glottic opening. Here are some stills from that video.

Photo of pedunculated laryngeal polyp in lowest position below vocal cords at end of inhalation

Photo of pedunculated laryngeal polyp in lowest position below vocal cords at end of inhalation

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Glidescope: Tricks For Successful Intubation

Glidescopes, one of the several videolaryngoscopes in use, are very easy to use. However, intubation with the Glidescope is very different than direct laryngoscopy. I have seen many novice Glidescope users struggle to intubate, despite having great views of the larynx. Failure to recognize the differences of using the Glidescope can make intubation not only frustrating but also hazardous to your patient. Beginners almost always make the same few easy to correct mistakes. Let’s explore those mistakes and discuss how to correct them.illustration of a glidescope intubation in cords section, with the view of the larynx behind in a monitor Continue reading

The Bougie: Use Wisely To Avoid Rare But Serious Complications

Inserting a bougie to assist with difficult intubation

Inserting a bougie to assist with difficult intubation

One of the simplest and most valuable devices to help with a difficult intubation is the bougie. The primary use is a difficult intubation, when you cannot see the larynx well but are able to predict where the glottic opening should be based on anatomy. However bougies must be used with care to avoid patient injury.

The bougie is an endotracheal introducer that is made of a braided polyester base with a resin coating, giving it both flexibility and stiffness at body temperature. The standard size for intubation is 15 Fr, which is 60 cm long. There is a 10 Fr pediatric version which can be used for endotracheal tubes as small as 4 to 6mm. A bougie will retain the curvature given to it, making it very useful for anterior airways. I highly recommend that you have a bougie in the room whenever you intubate because it is a quick and easy aide when the unexpected difficult intubation occurs. However, like so many of our tools you you have to use it wisely or you can seriously hurt your patient. Continue reading

Tips for Mastering the LMA Fastrach

The rare “can’t intubate-can’t ventilate” scenario is frightening. It’s important to master as many techniques as possible to prepare for this possibility. Video laryngoscopes have helped a lot with unexpected difficult intubations, but you can’t ventilate a patient with a Glidescope. One intubation device exists that is designed specifically designed to ventilate a patient intermittently during a prolonged intubation attempt: the LMA Fastrach.

Knowing how to use this tool could potentially save a patient’s life.  Using the Fastrach is not difficult. However, there are enough steps during intubation, as well as during safe removal of the device without accidental extubation, that  can make it seem intimidating. In addition to some tips and tricks that make it work, you’ll find a link below to a video clip of intubating a patient with the Fastrach.

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