You do perfect patient positioning.
You open the mouth.
A beautiful, gentle, stepwise insertion of the laryngoscope allows you to get the tip of your video Mac into the valeculla.
And you see…
Nothing!
What now?
Abandon the attempt–nope!
Use the Kovacs Kata
The Kovacs Kata is dedicated to my friend and airway Guru, George Kovacs.
George had described his EVLI approach to laryngoscopy as a kata (see EMCrit 236). That struck me more as mental rehearsal however. A kata in my martial arts experience was always a fight against multiple imaginary opponents. The way I taught the kata for rescuing a failed laryngoscopy is a fight against 5 opponents of success using 5 techniques:
1. Neck
Neck refers to external laryngeal manipulation (ELM).
2. Head
If you do not have a good view with your pre-intubation positioning, keep lifting and if necessary, flex the head.
- Kovacs Head Lift Video
- Keith Greenland on Why this Works
- Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy
3. Hands
If you are not strong enough to lift the patient's head off of the bed with one hand, use two. Then maintain the lift with one hand, aided by locking the left elbow against your body.
4. Scoop
If you have an epiglottis that you can't see past, despite the optimizations above, then just lift it with the Mac, i.e. use the Mac as a Miller.
- Levitan Article on Managing an Omega Epiglottis including the Scoop Maneuver
5. Pull Back
This one is for the hyperangulated blade. You have a great view–you just can't get the tube to go into the glottis.
- Why too close is too bad
- George on Hyperangulated Problem-Solving
- Levitan on HyperAngulated Blade Use and the Kovacs Sign
Additional Attributions
- Full Kata Video
Now on to the Vodcast…
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Scott Weingart
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[…] The Kovacs Kata for optimizing laryngoscopy from EMCrit […]
My 3 cts .
There is no upside for a mac 3 blade in anybody over 5 ft. Extra stick-out is ok within reason and a #3 and #4 are exactly the same height at the same length.
Your elbow should
always
be tucked in because of mechanical loop.
When it is that heavy, stop lifting with your arm, push with your legs. works best with the scope grabbed in the corner. Primary force will be axially on your forearm. It you can’t get it to move that way, do something different because something will break.
An addition at 10:00 on the video note that the patient is quite far away. Holding the head on the occiput ..I had a 195cm 160 kg patient with a buzzcut and a head the size of a planet and that doesn’t really work when you are that far away. If you move the patient all the way toward you, until you can can comfortably stand with the patients head against your body to keep the head in the position (flextention whatever it is now called). I tell residents to think how to fold the neck into a Z.. (Head on left z end C7 right lower end) . I found they tend to make the right movement afterward. You need to make a horizontal vector pointing caudal and slightly upwards to be stable and doing it by lifting a blade at a 45 degree angle with an extended arm is mechanically disadvantageous. Before you receive the blade, lift and position in Z position, then butt the head against your body (helper can put a hand in the neck) and you have neutralized most of the forces that are just annoying and you can just use sensible amounts of force… Read more »
Just out https://depthofanesthesia.com/optimal-position-for-viewing-the-glottic-opening/
Has a picture of what I meant.
Just out https://depthofanesthesia.com/optimal-position-for-viewing-the-glottic-opening/
Has a picture of what I meant.
it also has a review of litarature
Hi, i came across this reports. Had tried in on my patients, and i think they might be correct especially in reducing primary curve and soving hyperangulated problems. I hope you can elaborate or discuss more on this.
https://casereports.bmj.com/content/12/8/e230201
We have been discussing this article. here is my response:
when i still used Millers
the technique i used after having it beat into me by one of the anesthesiologists I most respected
was to put the blade in the right corner of the mouth to cut the shortest path to the glottis and eliminate all interaction with tongue
it seems they are using a similar strategy
it strikes me as silly for a number of reasons, not the least of which is the ease with which anatomy can be missed and you wind up with the blade in the goose
and as Bri has pointed out, this paper certainly is not the foundation you want to establish a new technique
An airway expert (not sure she would want to be publicly quoted) replied in part:
“I think there are more established ways to control the tongue – I can honestly say I can’t remember the last time a tongue was the problem for me, though I see it in my new trainees all the time. So the question should maybe be rewritten as “for inexperienced laryngoscopists, could left head angle help with tongue control, more reliably than other techniques?”. hmmm. how about just teaching laryngoscopy?”
All great and valid points. Although two handed laryngoscope operation seems a bit too much.
One thing I think is very important: if you don’t already know about this basic techniques, don’t know them by heart and don’t use them automatically, maybe you shouldnt be performing (advanced) airway management in the first place.
PS still using Miller blades for peds.
OR just call for an anesthesiologist 😉