Intubation During Cardiac Resuscitation

Intubating patients 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

A Flood of Blood in the Airway

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 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

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

Positioning The Head For Intubation

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

Tricks For Successful Intubation With The Glidescope

Illustration of the Glidescope Video Laryngoscope

Illustration of the Glidescope Video Laryngoscope

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. Continue reading