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#6Essential Emergency Airway Care-Video

Laryngoscopy

Andrew Brainard, MD, MPH, FACEM, FACEMhttp://www.thesharpend.org/

abrainard01@gmail.com

#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• <1 min

– Manual InLine Stabilization – Video laryngoscopy

• Indications/Contraindications • Advantages/disadvantages • Proper Technique

– Confirm and secure tube – Solving difficult tube passage

problems• Use suction early• Back off camera• Use prebent stylet • Pre-curve bougie• External Laryngeal Manipulation• Advance ETT off stylet

– Complete Airway Audit Form

• R40: 25y/o M rollover RTC– GCS 10, SaO2 98%, P 140, BP 140/70. – Agitated with head injury– In C-collar

• On arrival– LEMON shows:

• No facial trauma, No blood in airway, normal 3-3-2, gurgling

• Predicted difficult airway: in C-collar

– Consultant suggests Glidescope– Patient can only be intubated using

• Manual Inline Stabilization• Suction• Video laryngoscope

– Best Look Techniques– External Laryngeal Manipulation

• End scenario after tube confirmation• Discuss solving difficult tube passage

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Types of indirect laryngoscopes

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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

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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/ETCO2

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Nasal Apneic Oxygenation

• Apneic Period – Nasal cannula O2%

to >15 lpm– Jaw thrust / NPA /

laryngoscope

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Positioning

• Ear-to-sternal notch level

• Face parallel to ceiling

• RAMP• Head up• Bed height

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Formal Airway Assessment• LEMON– 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

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Teeth

TonsilsAnterior Tongue

Uvula

Posterior Tongue

Hard PalateSoft Palate

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4 step Glidescope

• Look directly at patient’s 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 stylet’ed ETT (or a prebent bougie)

into the mouth• Look again at the screen

– Advance ETT off stylet into the glottisUsing the Glidescopehttp://www.youtube.com/watch?v=7jb2tbqQ6VQ (3min)

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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 openingMore Glidescope

http://www.youtube.com/watch?v=BvpUI7vOpDw (6min)

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Difficulties with Glidescope?

• Lubricate exterior of blade, ETT and stylet• Remember geometry

• Use stylet • Prebend bougie

• Don’t “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) • Don’t 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/ (30min)

Common errors with glidescope: http://www.youtube.com/watch?v=0Z0s8875yc4

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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:•I’ll be team leader •JoAnn as primary airway operator •Fred will hold manual-inline c-spine stabilization•I’ll 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 <80% and dropping

• We will pullout if SaO2 drops below 93% or if we can’t see anything after 1 minute.

• We will re-oxygenate after each attempt.

• Everyone understand their roles?

• Questions or suggestions?

• Is everyone ready to complete the checklist in less than a minute?

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AndyJoAnnAndy

Andy

ChrisChris- Bimanual

Fred

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Brief Video Laryngoscopy References:

• Glidescope, 4-step technique: https://vimeo.com/38937634

• Levitan, Four Secrets to video laryngoscopy:

http://www.epmonthly.com/features/current-features/four-secrets-to-video-laryngoscopy-/

• Mihn, Learning from failed intubations- a study of 3 videos:

http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/

• John Doyle Eight Intubations using the Color GlideScope Video Laryngoscope

http://www.youtube.com/watch?v=BvpUI7vOpDw (Accessed on 24/4/2013)

• Levitan RM, Heitz JW, Sweeney M, Cooper RM. Ann Emerg Med. 2011 Mar;57(3):240-7. The

complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices.