Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – Airway Outsourcing and Suction Henching. EMCrit Blog. Published on July 16, 2012. Accessed on December 11th 2024. Available at [https://emcrit.org/emcrit/airway-outsourcing-and-suction-henching/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: July 16, 2012
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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Hi Scott, I am humbled that my comments merited their own wee from the master resuscitationist… So, I agree with everything you said but it is predicated on the notion that you are using video laryngoscopy (and probably a system with a screen on a stand, not the handle) rather than the classic Macintosh blade. Minh’s concept of having resilient practices strikes a cord here, ie. your team can adapt to other methods of getting a tube in. So I still feel that training the intubator to reach for the larynx every time is a better approach. With a classic… Read more »
Scott, Sean, this is quite a thought provoking issue you raise. In many ways, we are defining and describing a new paradigm in emergency airway management. bougie prepass, criccon, DSI, RSA, suction outsourcing..these are all things still quite alien to the OR anaesthesia setting. even RSI checklists are not standard in the OR. so the question is what should be the standard of emergency airway training curriculum for the frontline provider? Is it gained and set in the OR, ICU or ED? Does it matter? There is room and a necessity for evolution and innovation in emergency airway management ,… Read more »
Minh,
Great comments as always. It’s funny all of my work around airway is an attempt to take the chaos of the critical care airway and evolve it till it feels nice and quiet like an OR. I’ll know I can retire when I can be an old geezer watching some of the juniors progressing through an airway paradigm all the way to cric without ever raising their voices or any of the patients in the next bay even realizing something is going on.
Nice Wee Scott. I find myself being the hench person (man-woman) most of the time nowdays. Did this a couple of times last week in fact – once doing a ketamine DSI on young chap with bad pneumonia who developed trismus post ketamine that took 200 mg of sux and some propofol to break – fairly hairy and glad of the bougie/vid laryngoscope. Interestingly, the high-flow nasal prongs we used during the DSI were a real hindrance to proper bagging as we couldn’t get a good seal until we got rid of them.
Keep up the good work!
Oli
It is interesting; are you folks using the EC technique or thumbs forward? I am beginning to think that folks that are having seal problems are using EC; which is why I have never had a problem.
For folks that don’t know him, Oli runs an AMAZING criticial care podcast which you can find on the Intensive Care Network Site.
Friends and Colleagues I am a happy follower of this blog. However, after following the airway management debate I felt it was time to contribute… despite NOT being an Anglo-Saxon emergency physician.. With a training background as dual specialist in Scandinavia in anesthesia and intensive care which includes being the resuscitator (since there are no emergency physicians here) in ED as well as working a large proportion of my time in the pre hospital arena. I feel an urge to comment on this debate… First, outsourcing suction is NO new thing, we do that all the time in theatre and… Read more »
thanks so much for commenting. a few points of clarification: DSI is not a controlled induction, which is absolutely standard practice. It is a crash dissociation in a critically ill patient. Actually despite the all-caps as proof, if you are both looking at the same video screen there is absolutely no advantage to the intubator performing the ext. larygneal manipulation. I am glad we share a fundamental respect for the basics of airway management: good laryngoscopy skills, peri-intubation knowledge of drugs and sequencing, etc. However, what you dismiss as gadgetry and fancy names is what needs to be done when… Read more »
Hi This is great – blogs, debate, exchange of experiences, attitudes… Many good points in your answer. One thing that I find important to emphasize, is around location. YES, I agree, that it is different to intubate/anesthesize+intubate outside OR. However, one need to think that it is a similar procedure. The absolute SAME things NEED need to happen! Positioning, potentially preoxygenation, drugs, airway handling.. all the same.. same sequence as well. What differs is the location, supporting staff around you, knowledge of the patient… BUT when preparing for intubation, one need to think the same… one can easily, be training,… Read more »
“Crash” is a description of the patient condition not a resuscitator mindset, but I chalk this up to different uses in different countries. With the way we use the word, of course there are crash situations. Now as to bringing the same preparation and sequencing to both venues we agree. Where we differ is which venue needs to be emulated. Here is the preparation and sequencing we do at our institutions: Sinai Intubation Checklist. If you do the same level of preparation in all of your operative cases then I commend you; if you want to tell me that all… Read more »
I think Viking’s comments are directed at aspiring primary responder clinicians (reading this blog) who may have an unhealthy focus on advanced airway tools but lack the fundamental knowledge and skills to perform an intubation meticulously and correctly in conventional manner. By all means have your bag of tricks at the ready but don’t rummage around in them simply because you are unpractised or possess poor technique.