#6 essential emergency airway care- video laryngoscopy
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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.
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