Posts Tagged airway

Placing the Intubating Laryngeal Airway

My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook (As always, I have no conflicts of interest). He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways in general. Sorry about the audio quality, his cell phone was probably AT&T : ).

[Click Here to Read More and to Hear the Episode]

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Interview with EMS Physician, Cliff Reid

I was able to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff’s blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Cliff and I discuss prehospital intubations, helicopters for EMS, and upstairs care, outside the walls of the hospital.

[Click here to read more and hear the podcast]

photo by mad scientist

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Delayed Sequence Intubation (DSI)

The Case

You have a 50 y/o male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick! Saturation is 70% on a nasal cannula; when you try to place the patient on a non-rebreather (NRB) he just swats your hand away and rips off the mask. It is obvious to everyone in the room that this patient needs intubation, but the question is how are you going to do it?

Your first impulse may be to perform RSI, maybe with some bagging during the paralysis period. This is essentially a gamble. If you have first pass success, you (and your patient) may just luck out, allowing you to get the tube in and start ventilation before critical desaturation and the resultant hemodynamic instability. However, the odds are against you: bagging during RSI predisposes to aspiration, conventional BVM without a PEEP valve is unlikely to raise the saturation in this shunted patient, and if there is any difficulty in first-pass tube placement your patient will be in a very bad place.

Is There a Better Way???

[Read and Listen to the DSI Podcast]

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Gravity is your friend

Why are we still laying patients flat to intubate?

Intubating a patient in a low semi-fowlers position (head of bed 30-45 degrees)Semifowlers makes intubating much easier for several reasons.  Gravity pulls intestinal contents away from the thorax, making it easier to bag a patient and helps pull extra tissue away from the airway, since, let’s face it, some of our patients have a little extra tissue around the airway.   Stomach contents don’t join the party as easily, especially in those who made the mandatory stop at Taco Bell® on the way to the hospital though I still advise cricoid pressure.  The airway is in much better position and is easier to visualize.  Also, semi-fowler positioning relieves arm strain on the practitioner because the airway is attached to a bowling ball.  Much less force is required to just pull down the jaw than to lift the whole head.  As an added bonus, it is kinder to your back- no stooping required.

The next time you intubate, consider using semi-fowlers positioning, if you aren’t already.  Remember- gravity is your friend!

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Open Cricothyrotomy in Many Different Flavors

Ok, Ok, I promise this is the last airway episode for at least a little while. I am perhaps a bit obsessed. Had this show in the works for a while. The cric is the last barrier between a failed airway and death. EM docs need to be able to perform this procedure without hesitation. This requires training and practice until you can perform the procedure in < 30 seconds literally with your eyes closed!

In EMCrit Podcast # 24, we discuss numerous ways to perform an open cricothyrotomy including interviews and videos from Darren Braude and Seth Manoach.

[Click Here to Read More and Hear the Podcast]

Photo from wikipedia

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Who is this awake intubation stuff for anyway?

So after the awake intubation video went up on emrap tv, I got a flurry of emails telling me how cool the concept is, but questioning who this would actually be usable on.

To answer that question, we first must discuss who actually requires intubation. If you wait until the patient is apneic, then of course you can’t use awake intubation. The idea is to intubate before the patient stops breathing. If you predict a patient is a difficult airway, you can and should perform the intubation awake.

In EMCrit Podcast 23, I discuss who actually requires intubation and which of these patients can be done awake.

I also discuss a new indication for awake intubation: the hypotensive trauma patient.

[click here to read more and hear the podcast]

photo by pig sty ave

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Learn to Love the Mask

photo by upeslases

Intubation is a sexy procedure, there is no doubt about it.

In the EMCrit podcast # 19, I discuss Non-Invasive Ventilation. NIV does not have the glamor; it’s not nearly as cinematic as endotracheal intubation. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.

It is pretty simple as the mode only has 3 main settings:

[Read More and Hear the Podcast]

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Stupid Human Tricks: The Jaw Thrust

Decided to try my hand — erm, face — at video blogging. It’s no watching two fellows intubate each other, but then again, I am no Scott Weingart. And away we go.

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