Video for Podcast 43 – Inserting the Air-Q

Folks have asked for a video to go with Podcast 43 and as always I do what folks ask for.

 

PlayPlay

EMCrit Podcast 43 – Laryngeal Airways with Daniel Cook, MD (Part I)

My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. 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. Part II will specifically discuss the new device.

Placement of the ILA

  • Put the patient in sniffing position
  • Lube it really well (get the bottom, the cuff, and the horizontal ridges up front)
  • Dr. Cook recommends an insertion using a tongue depressor to pull the tube forward. He inserts straight back instead of riding the hard palate. If the LMA doesn’t quite turn the corner, he inserts his left index finger just posterior to the tip and flexes his finger to get the LMA to make the curve into the lower pharynx
  • He gently advances until the LMA comes to a rest—don’t push too hard
  • At this point he puts 4-5 cc of air in for the 4.5 size and 3-4 cc of air for the 3.5 size (same amount of air as the size of the LMA)

Blind Intubation through the ILA

  • First step is to lube the inside of the ILA. Use the ET tube itself—put a big glob of lube on the distal portion of the ETT and then advance it until it is just about to pop out of the keyhole opening of the ILA. This distance will be 20 cm in the 4.5 size and 18 cm in the 3.5 size (keep subtracting 2cm for each downsizing)
  • Now readvance the ETT to that same point, put your index finger on the top and use it to ever so slowly advance the ET. You can have a hand over the cricoid to feel the ETT as it passes.
  • Inflate and confirm by listening over the stomach and looking for End-Tidal CO2.
  • If you missed, pull back to that same point that is just before the opening of the cuff and inflate the ETT cuff with 1-2 cc of air. You can now reoxygenate the patient before your next attempt.
  • The second attempt should probably be with a fiberoptic device or a bougie.

Bougie Intubation through the ILA

  • First lube the ILA using the ETT, then remove the ETT
  • Advance the bougie using the coude end with the coude facing towards the ceiling.

 

Here is the podcast:

Play

EMCrit Podcast 41 – Interview with Cliff Reid of RESUS.me

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 mentions the HEMS service in London. This amazing service sends a physician/paramedic team to the scenes of bad traumas by helicopter and response cars. A well done video is available on youtube:

The winner of the Toxicology Handbook is Jenny Mendelson. Yeah!!!

photo by Mad Scientist

Click Here to Play the Podcast

Play

EMCrit Podcast 40 – Delayed Sequence Intubation (DSI)

This is the DSI Podcast. If you want all of the great DSI information, please come to the EMCrit Delayed Sequence Intubation (DSI) Page

 

 

Play

Bougie-Aided Cricothyrotomy by Darren Braude

Darren Braude, Aiway and EMS master from New Mexico demonstrates the use of a bougie to make the cric procedure MUCH easier. For more great Braude magic, see his site at airway911.com.

 

 

 

Procedure: Open Cricothyrotomy

The only way I recommend performing cricothyrotomy since 2011 is the Bougie-Aided Cricothyrotomy

Here is an actual Cricothyrotomy

My friend Yen made this cheat sheet for bougie-aided cric

For historical purposes only, here is my video on performing open cricothyrotomy in 3 situations: with a trach set and an assistant, with a trach set when alone, and when you only have a scalpel.

I did a podcast on cricothyrotomies

and then I debated Minh Le Cong on Needle vs. Knife for surgical airways

My friend Ram Reddy has a bunch of great videos expanding on this topic

 

EMCrit Podcast 24 – The Cric Show

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!

On this show:

Since you need to practice and patients get a wee bit pissed if they wake up with an unnecessary, unexpected tube in their neck, you need something to train on. Pig trachs smell and are not great training IMNSHO. Instead, read this article:

Anaesthesia 2004;59:1012

Here is the picture

With this set-up, which costs nothing, you can practice as many times as necessary any time you like. You’ll see my version of the set-up in my video below.

I prefer surgical crics. I think wire-based seldinger kits fail badly when stress is involved. That is opinion. They are also entirely too slow; that is FACT.

Anaesth Anal 2010;110(4):1083 & Anaesthesia 2006;61:565

Here is a video with the three techniques I prefer for crics

Click here to go to the video post

Next we talk to my friend Seth Manoach, another of the ED Intensivist clan. He has a technique for fiberoptic-stylet guided crics.

Click here to see the video

Last, we talk to Darren Braude of airway911.com fame and author of the book Rapid Sequence Intubation & Rapid Sequence Airway. Darren has a technique for bougie-aided cric that you are going to love.

Click here to see the video

photo from wikipedia

.

Play

EMCrit Podcast 23 – Awake Intubation for Trauma and Medical Patients

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.

In Ron Walls’ airway manual and in his class, he gives the following reasons for intubation:

Crash-a patient who is dead or near dead

Can’t Protect Airway

Can’t Maintain Ventilation/Oxygenation

Expected decline in Clinical Status

Now some of these make sense and some not so much

Here are my reasons to intubate:

Crash-for me this is any apneic patient

Can’t Protect Airway-this one is good, a patient with pooling secretions or obtundation with vomiting buys plastic

Possible Loss of Airway-angioedema, anaphylaxis, neck trauma. These are good reasons to intubate and usually earlier is better and safer.

Oxygenation/Ventilation issues for me mean you intervene. But this doesn’t necessarily mean intubation, if the patient has a reversible problem, put them on Non-invasive instead of intubating. See the podcast.

So it all comes down to the last reason

Expected decline-this should be the reason for many ED intubations. If the patient has O2/CO2 issues and they will be getting worse, then consider intubation.

Supply/Demand Imbalance-Last reason, not discussed as often in the ED is severe metabolic acidosis or shock where the lungs are causing a huge metabolic demand in a patient without much supply.

So who can be intubated awake? Any patient except the crash airway can be intubated awake. If you think they are a difficult airway, temporize with NIV while you topically anesthetize and then do the patient awake while they keep breathing.

Who is a difficult airway, there are few good answers.

THe LEMON rule also coined by the Walls crew is probably as good as any:

Look at head and neck

Evaluate 3-3-2

Mallampati

Obstruction

Neck Mobility

see here for more

I also discuss a new possible indication for awake intubation

photo by pig sty ave
Play

EMCrit Podcast 19 – Non-Invasive Ventilation

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

NIV does not have the glamour; it’s not nearly as cinematic. 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:

FiO2 – set based on oxygen requirements, just like on the vent

PEEP/EPAP/CPAP – all the same thing, set this based on OXYGENATION needs. If the patient’s sat is low, start at 5 cm H20 and titrate up to 15-17 as needed.

PSV/IPAP – this setting is for ventilation. If your patient does not have ventilation problems, they don’t need PSV. If they do, start at 5 cm H20 and titrate to 15-17.

Yes, that’s right, I did not tell you to put every patient at 10/5. Very few of your patients will have both ventilatory and oxygenation problems. Asthma and COPD need inspiratory support. APE, atelectasis, pneumonia patients need PEEP.

I also talk about sedation while a patient is on NIV.

Play

EMCrit Podcast 18 – The Infamous Awake Intubation Video

This post marks the return of the Awake Intubation Video. If you’ve seen it, we will have a brand new post early next week. If you haven’t, well you are in for a treat:

Awake Intubation can save your butt!

It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can attempt an intubation on a difficult airway with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

Click Here to Download the Video

Look for this area in the lower right of the screen

Here is the procedure for ED Awake Intubation–EMCrit Style:

DRY THEM OUT & PRETREAT GAG(Do All)

If you can give it early 10-15 min before topicalizing, it will be most effective.

  • Glycopyrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible)
  • Suction and then pad mouth dry with gauze – you want the mouth very dry!
  • Adminster Odansetron 4mg IV to blunt the gag-reflex

TOPICALIZE (Do All)

  • 5 cc of 4% lidocaine nebulized @ 5 liters per min
  • Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit
  • Spray the epiglottis, cords, and trachea with 4% lidocaine (3 cc) in a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection
  • Have another syringe loaded with 4% lidocaine to spray with during the procedure

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol’ windpipe.

SEDATE (Choose one!)

  • Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient’s hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable.
  • Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so.
  • If you have it, Dexmedetomidine also works very well as long as your patient is not bradycardic.
  • If you have neither of these 2 mg of midazolam will do just fine.
  • Preoxygenate with NRB

  • Optimally position (ear to sternal notch) with the head tilted all the way back

  • Restrain both arms with soft restraints to prevent the “grabbies”

  • Switch to nasal cannula

  • INTUBATE with Fiberoptic laryngoscope and bougie

  • If the patient coughs or is uncomfortable after placing the bougie through the cords, push more med from the ketofol syringe.

  • Thread  the tube over the bougie with the laryngoscope still in the mouth

  • Confirm tube placement

That’s all for this week

For more info on awake ED intubation, you can view a complete lecture here

Thanks to Raghu and Xun for risking their singing careers and to Jimmy & Anita for technical support. *
The opinions on this site and in the video represent the author’s and not the opinions or policies of the Mount Sinai School of Medicine or Elmhurst Hospital Center. It is not my intention to provide specific medical advice for any individual patient. Please confirm anything on this video with your own clinical judgment and the policies and procedures of your institution. This video is for education purposes only; it does not represent a standard of care or clinical advice.