Friend to the show, Jim DuCanto has been obsessed with SALAD. Not the leafy greens delicately touched with a tart emulsion, but with Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). Jim DuCanto, MD is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.
COI Statement
Dr. DuCanto invented and receives royalties on the DuCanto Catheter from SSCOR and the Nasco SALAD mannequin
Read More about SALAD from Taming the Sru
Esophageal Diversion Maneuver (Intentional Esophageal Intubation)
deliberately insert the ETT down the esophagus and gently inflate the balloon
There is lit for this [cite source='pubmed']25943615[/cite]
SALAD Park Maneuver
Keep tip of suction catheter in the esophagus on the left side of the mouth
SALAD Techniques
Meconium Suction Set-Up
Here was our original letter (J Clin Anesth, 23 (2011), pp. 518–519) (fulltext)
It was recently validated (The Journal of Emergency Medicine Volume 52, Issue 4, April 2017, Pages 433–437)
Large Bore Suction Surrogate
Wanted to run something by you. I'm an EM-3 in Cleveland at University Hospitals rotating up in the CT-ICU at my institution with a CA-2. We were just fooling around with mechanisms to make large bore suction improvisation kits, and stumbled upon a VERY good one I didn't see on your site. 7.0 ETT with the adapter pulled off. Hook that up to suction EXTENSION tubing with the little white plastic adapter that comes with the extension tubing. Connect that tubing adapter directly to the 7.0 ETT on one end, and the tubing it is meant for on the other. Should have a small gap of that adapter bridging between the tubing end (traditionally a blue end I believe) and the ETT. Doesn't work with larger bores we found out. Easy as that. Drained 750cc of fluid in less than 3 seconds on repeat testing with continuous suction. No meconium aspirator needed (for those working in the community), and because it is an ETT, there is the built in hole at the end of the tube to prevent suck down events onto tissue in the oropharynx.
-Chris Peluso ( cfpeluso10@gmail.com )
SALAD Comic
More Stuff
- SALAD Facebook Page
- SSCOR Site
- Taming the SRU write-up of SALAD
- DuCanto Suction Catheter
- General Description of system and demonstration by Jeff Hill of the University of Cincinnati’s EM Program
- Product page of SALAD Mannequin
- University of Wisconsin HEMS Fellow with the “Static” Excercise
- University of Wisconsin HEMS Fellow with the “Dynamic” Excercise
- University of Wisconsin HEMS Attending takes on the SALAD Simulator
- Check out the next level of SALAD—SALAD 2.0
- Listen to the JellyBean with Jim
More from Jim DuCanto on EMCrit
- Podcast 73 – Airway Tips and Tricks
- A New Bougie for your Pocket by Jim DuCanto
- A Guide to Intubating through the Intubating Laryngeal Airway
- Two New Videos from Jim DuCanto
- The Oxylator
- More DuCanto and Pocket Bougie Videos
- Two OR Intubation Videos
- How to Custom Bend a Video Stylet for use with the Cookgas AirQ ILA
image at the top from J Downham
Now on to the Podcast…
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Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
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Love hearing from Dr. DuCanto about this technique, I’ve been practicing it on mannequins since I saw one of the first videos of it (thankfully not had to employ it yet). Just curious if either of you has anecdotal, or other, experience of apneic oxygenation still being effective with the SALAD technique?
Hi Ben, sorry for the delay in answering your question-I forgot to re-check the podcast page. I do not have any experience or evidence regarding apneic oxygenation with the SALAD technique, other than the realizations that: 1. Apneic oxygenation only works with an OPEN airway free of airway obstructions, so the decontamination maneuvers must be thorough enough to allow the flow of oxygen without obstruction to the trachea (so airway decontamination would be as important as the oral airway or manual airway maneuver to the patient to maintain that open airway). 2. If the rigid suction catheter is parked within… Read more »
I’m a Critical Care Paramedic in Canada and I’m hoping that in light of the information presented in this excellent podcast that you may be able to settle a long standing debate between myself and my peers on a related topic. Meconium aspiration? So you have a newborn with obvious signs of staining and meconium present in the upper airways from what you can gather on your initial assess. Pt is markedly brady and cyanotic. According to local protocols, my colleagues advocate for immediately attempting to correct the respiratory issues with BVM regardless of the presence of thick contaminate in… Read more »
Again, sorry for the delay in answering your question. Now that SMACC is over, I can look around and close up loose ends. Great question, and I believe that as we consider the importance of this topic together in medicine across multiple disciplines, we may engage with the thought-leaders and protocol-writers to make reasonable, effective and frankly more medically relevant changes in these protocols. We will start this world-wide project in airway management quality improvement in adults, and bring it around to the pediatric and neonatal fields as well (a peds mannequin is being produced for this simulation by Nasco… Read more »
Great Podcast Scott. After listening to your initial podcast regarding the meconium aspirator+ETT I’ve carried a meconium aspirator in my pocket religiously, just in case. (I do get a lot of weird looks from my co-workers). So far I’ve only had to use it once (actually suggested it to an overwhelmed ED physician) and it worked amazingly well. Standard scenario of major head and chest trauma with copious and ongoing blood in the airway. Suggested your set-up and using the C-Mac the physician was able to clear the airway and place the tube-still in the suction configuration. I think it… Read more »
Hi Dean, I am not sure how to answer what constitutes a repeated attempt, but in my anesthesia practice, I count attempts as the number of times I perform the laryngoscopy when doing direct laryngoscopy. When tube passage is not possible with video laryngoscopy and the blade requires re-positioning to get the tube into a trajectory for proper passage, I would count that as a repeat attempt personally. Sorry I cannot give you a better answer. A better answer takes into account the need to minimize apnea time I guess.
Here is our attempt at the SALAD sim, I think it has some neat tweaks to the concept.
http://croaker260ems.blogspot.com/2017/04/the-vomikin.html
We would have them go through as a “team”. Our station evolution for this training was:
SALAD decontamination, then Esophageal Diversion thenIntubation with Bougie around the esophageal diversion tube. NOTE: I would have them use a meconium aspirator on the #9 ETT instead of simply sticking the suction tubing in the ETT. Then apply in line suction for tracheal suctioning.
Hi Steve, sorry for the delay in engaging with you– could you post that link again, it was not going through (although I’m web surfing from Rome from the moment following dasSMACC). Otherwise, instant message me on twitter @jducanto.
Jim,
I think you may have already commented onthis via my blog or on some other social media platform, but here it is again.
http://croaker260ems.blogspot.com/2017/04/the-vomikin-salad-airway-trainer.html
Many thanks!
Steve
Question for Dr. Cuanto. Has here been consideration for a separate channel for the bougie in the ducuanto suction catheter? It seems it would be cool to be able to pass the bougie while suction was still running.
Hi Zac, sorry for the delay in answering your question.
I’ve made mock-ups of just such a system (looks like a double-barrel, sided-by-side shotgun), but have concluded that it works great in simulation but would be bulky in actual practice at the present time. Current FDA labeling on rigid suction catheters are another concern (in other words, a company will not make something that the FDA will not let them sell), however, and in a few short years, we may have an opportunity to make such a “creature catheter.” Thanks for your question and excellent suggestion!
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Hi Dr DuCanto and Weingart.
I used the ” SALAD park” technique while intubating a pt with massive liquid vomiting and I was able to get the airway after a failed attempt by another provider.
I wouldn’t have been able to get it without you guys. Thank you for all the valuable knowledge you have spread.
Sweet! Thanks for sharing!
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