Thanks Scott. Again we feel privileged to learn from those that have gifted their bodies to the Human Body Donation Program. They are prepared in a manner similar to what is used by Rich Levitan in Baltimore. We have modified the preparation over the years and the resultant clinical cadavers truly provide human tissue experience that is often indistinguishable from that of the living. Regarding our findings I agree that this warrants caution regarding holdup. However I don’t think it should be avoided (sit down Minh). I think the message is that you can get false positive holdup although usually… Read more »

Thanks so much for addressing this topic, folks. Having taught bougie-aided cric in dozens of cadaver labs, the conclusion I’ve come to is that holdup in a false passage occurs at 15cm (at least in adults) the vast majority of the time. Therefore, I still use holdup, but if it occurs at <15cm, I'm especially wary that bougie may not be in the trachea, and I'm going to palpate again with my finger prior to placing a tube over the bougie. I like Dr. Kovacs' combined end-point above, although of course, since I get paid to be paranoid, even with… Read more »

Hi Scott While these are different circumstances, it is an example of an airway adjunct (cook airway exchange catheter) being misplaced, contributing to arrest. The post mortem showed the catheter through the right middle lobe and in the chest wall. How much of each step contributed to the arrest (for example, oxygen through the catheter at 15 lpm wouldn’t have helped even if it was wedged in the RML without perforation), I don’t know, but to answer the question if this sort of thing is possible, this example shows that it is. Rare, but possible. It was enough to change… Read more »

Disclaimer: Zero experience with this in the emergency situation.

BUT, I visited a US top tier Level 1 trauma centre recently as an observer and they have a skin hook in their ‘finger-scalpel-bougie’ packs to hook the anterior wall of the trachea inferior to the incision forward, much in the manner of using a laryngoscope. They say this gives good direct vision of the trachea and makes insertion much easier.

Comments?

Hey Scott,

If you no longer recommend hold up for secondary confirmation and primary confirmation occurs by feeling the bougie pass next to your finger after your finger has already confirmed you are in the cartilage cage, what’s the point of using the bougie at all. Why not use the Scalpel-finger-tube method as per the Paix & Griggs article?
https://emcrit.org/wp-content/uploads/2014/08/EMA-Scalpel-FInger-Bougie.pdf
You would still get the same tactile confirmation of the tube passing by your finger.