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#6 Essential Emergency Airway Care- Video Laryngoscopy 1 Andrew Brainard, MD, MPH, FACEM, FACEM http://www.thesharpend.org/ abrainard01@gmail.com

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#6 RSI and Video Laryngoscopy Learning Objectives Prep team/plan/room/equipment Mask seal, BVM, adjuncts, suction Pre and apnoeic oxygenation Pt Positioning Airway assessment and plan MOANS/LEMON Announce pullout criteria Briefing for Plan A, B, C, & D Completes FINAL airway checklist Call and response

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Types of indirect laryngoscopes 3

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Indications for Video Laryngoscopy? Absolute Contraindication: Inability to oxygenate patient Cricothyrotomy Indicated for: Primary Secondary Relative Indications: Predicted difficult airway? Spinal precautions? Relative Contraindications: Fluid in the airway (like blood or vomitus) that cannot be cleared with suction Operator inexperience Reserving VL as only a rescue device is dangerous Practice before you need it as a rescue device 4

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5 Direct Laryngoscopy Video Laryngoscopy

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Pre-Oxygenate >3min (Attempt to get oxygen to 100% for several minutes before RSI) Non-Hypoxic patient Nasal Cannula Oxygen as high as tolerated Rebreather Mask Oxygen as high as tolerated Non-Hypoxic or Hypoxic/Hypoventilating Patient Nasal Cannula Oxygen as high as tolerated BVM Mask Seal/PEEP/ETCO 2 6

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Nasal Apneic Oxygenation Apneic Period Nasal cannula O2% to >15 lpm Jaw thrust / NPA / laryngoscope 7

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Positioning Ear-to-sternal notch level Face parallel to ceiling RAMP Head up Bed height 8

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Formal Airway Assessment LE M ON L- Look E- Evaluate the 3-3-2 rule 3 pt fingers in the mouth 3 pt fingers under the jaw 2 pt fingers from thyroid to jaw M- Mallampati / Mouth O- Obstruction N- Neck Mobility Fluids can make video laryngoscopy more difficult 9

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10 Teeth Tonsils Anterior Tongue Uvula Posterior Tongue Hard Palate Soft Palate

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4 step Glidescope Look directly at patients mouth Insert midline Use suction early Watch mouth until tip passes out of view Look at the screen after tip passes into posterior oropharynx. Use screen to visualize epiglottis. Insert tip of into vallecula Apply upward pressure Visualize the vocal cords and glottis Suction if needed. Look at the mouth Pass the styleted ETT (or a prebent bougie) into the mouth Look again at the screen Advance ETT off stylet into the glottis Using the Glidescope http://www.youtube.com/watch?v=7jb2tbqQ6VQhttp://www.youtube.com/watch?v=7jb2tbqQ6VQ (3min) 11

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Epiglottis-Laryngoscopy-Tube Passage #1- Prepare Prepare Team- (EEACC #1) Optimize pt Oxygenate pt- (EEACC #2) Position optimally - (EEACC #2) Prepare Glidescope Warm up Select blade size ~4 for tall men ~3 for most patients #2- Visualize Epiglottis Mouth then Screen #3- Visualize Glottis Place blade above vallecula Visualize the arytenoid cartilage #4- Pass Tube Watch mouth and insert tube Watch screen Re-maximize your view Advance tube through glottic opening Advance tube off stylet through the glottic opening More Glidescope http://www.youtube.com/watch?v=BvpUI7vOpDwhttp://www.youtube.com/watch?v=BvpUI7vOpDw (6min) 12

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Difficulties with Glidescope? Lubricate exterior of blade, ETT and stylet Remember geometry Use stylet Prebend bougie Dont Over Zoom Keep camera far away from glottis Backing up camera Keep epiglottis in view Place the blade above vallecula Glottis in the centre top third of screen Manipulate patient Elevate head, lift jaw, use ELM Advance ETT off end of tube Withdraw the stylet Advance tube off end of stylet through the cords (like an IV cath) Dont task-fixate on the picture Watch the sats Prepare plan B, C, D Difficult Video Laryngoscopy: http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ (30min) Common errors with glidescope: http://www.youtube.com/watch?v=0Z0s8875yc4 http://www.youtube.com/watch?v=0Z0s8875yc4 13

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Airway briefing and checklist We have a 50y/o female victim of head trauma who needs to be intubated because she is not protecting her airway. Based on our formal airway assessment, it is appropriate to proceed. We will RSI with 100mg of Ketamine and 100mg of Rocuronium. The team will be: Ill be team leader JoAnn as primary airway operator Fred will hold manual-inline c-spine stabilization Ill be the backup airway operator Chris as airway assistant Henry also push the drugs Our plan is: A- Video/7.5 tube w/stylet B- Direct/bougie/7.5 tube C- AirQsize #3.5 D- Cric for Sats