LMA FOI - You Mean You Can Intubate through that Thing?

/
LMA FOI - You Mean You Can Intubate through that Thing?

Emergency airway management is being revolutionized. Think about it…those of us who are in training now are being exposed to some very different core skills. The big culprit is the recent advent of video laryngoscopy – not much argument there.

With that said, I will argue that almost as significant as the advent of video laryngoscopy from a general “airway management revolution” perspective is the philosophical change of many pre-hospital providers in that it is becoming the norm for extra-glottic devices to be placed primarily, or at least considerably more often than in the past.

It is likely that the rate of field placement of extra-glottic devices will become more common. Thus, we will probably see many more patients present to the ED in whom EMS has placed an extra-glottic. As we recognize the power of extra-glottic devices, I think that even the most advanced airway managers will use extra-glottic devices with more frequency to facilitate rescue oxygenation and ventilation.

This begs the obvious question: should we remove these devices after they are in and working?

Read More

Video Laryngoscopy in the Field? Absolutely

/
Video Laryngoscopy in the Field? Absolutely

Close your eyes... actually open them up, you won't be able to read the description if you close your eyes... Imagine you are on flying on the helicopter for a scene flight.  You land and are brought to the patient, a victim of a motorcycle accident who is clearly in need of an airway.  He is obtunded with sonorous respirations, a GCS of 6, O2 sats in the low 90's.  You start to look and assess the patient's airway and you are decidedly less than pleased.

Read More

Rescue Me

/
Rescue Me

Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

Read More

Decision is a Sharp Knife

/
Decision is a Sharp Knife

In emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).”  I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.

Read More

Needle Cricothyrotomy

/
Needle Cricothyrotomy

Circumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.

In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.

Read More

So You Want to Tomahawk Somebody?

/
So You Want to Tomahawk Somebody?

If you took a listen to our last podcast or inferred from our most recent post, the "challenging airway" that was described was managed by way of a tomahawk intubation.  As we discussed in the podcast, there were a number of different ways we could have elected to manage that patient's airway including intubation from the back of the stretcher with the patient seated upright, awake fiberoptic intubation (both nasotracheal and oropharyngeal with the assistance of a Williams airway), tomahawk intubation, or, as was suggested by one of the residents (nice suggestion Dr. Cousar) after our simulation (on the same case), through a bronch adapter hooked to a LMA...

Read More

What Makes an Airway Difficult

/
What Makes an Airway Difficult

What Makes an Airway Difficult? In short, a lot of different factors play into making an airway difficult.  In general, they can be broken down into anatomic, physiologic, and logistic.  We'll cover some of the logistical issues that can complicate intubations on a later post (mostly with regards to intubation in the HEMS and prehospital  setting).

Read More

Oxygen is Good, Methods for Delivery Often are Not

/
Oxygen is Good, Methods for Delivery Often are Not

An elderly patient with steroid and oxygen dependent COPD, and NYHA Class IV CHF, presents with dyspnea.  The patient is alert but looks somewhat desperate, confused, and exhausted.  Exam reveals accessory muscle use, grunting expirations, poor air movement, and cool clammy skin.  The patient speaks in two-word phrases.  Attempts to improve the situation are made with Lasix, nebulizers, and non-invasive ventilatory support.  The patient cannot tolerate BiPAP due to anxiety.

Read More

Look Before You Leap - Awake Fiberoptic Intubation

/
Look Before You Leap - Awake Fiberoptic Intubation

Look Before You Leap, Drive Your Ferrari Like it is a Wheelchair, Harken Ye to the Wicked Witch of the West!

A 37 year-old woman presents with stridor, drooling, tachypnea and accessory respiratory muscle use.  She has an adequate blood pressure, but is tachycardic to 120.  Her oxygen saturation on room air is a reassuring 97%.  She cannot answer questions, appears to have an altered mental status though she follows commands, and suddenly has a brief period of either myoclonus or seizure with unresponsiveness.  No post-ictal period is noted after this episode.

Read More

Awake Fiberoptic Intubation

/
Awake Fiberoptic Intubation

Like all procedures, success in the performance of an awake fiberoptic intubation comes from proper preparation.  Preparation for this procedure means so much more than proper preparation of the patient (preoxygenation, positioning, local anesthesia, etc.).  To be fully prepared is to have a well practiced, working knowledge of your equipment and the options you have in setting it up.  To be fully prepared is to be practiced in the motor skills necessary to drive the scope, advance the tube and troubleshoot as you go.

Read More

The Decision to Intubate

/
The Decision to Intubate

The I.C. Cordes College of Airway Knowledge, written by Dr. Steven Carleton, is known to many who have passed through our doors.  Today, however, we begin to set them free to the #FOAMed world starting off with I.C. Cordes #1 - The Decision to Intubate.  I felt like I had found a mint copy of the Amazing Fantasy Introducing Spiderman comic book or a Honus Wagner baseball card receiving these collected cases by email from Dr. Carleton earlier today. - Jeffery Hill, MD

Read More