Pearl #10. Respect the vomit
Pearl #9. Don't insert the laryngoscope until at least 60 seconds after pushing rocuronium.
Pearl #8. Don't over-utilize awake intubation
Pearl #7. Consider a standard-geometry blade with video capability as your go-to blade for most challenging airways.
Pearl #6. Not all MAC-4 blades are created equal
Pearl #5. Consider a stepwise midline approach if there is difficulty finding the epiglottis.
Pearl #4. Have a strategy for improving a Grade IV View (epiglottis-only) with a Macintosh blade.
- (a) Head elevation. This may be achieved by exerting force along the line of the laryngoscope handle, or by directly lifting the back of the head (often with the help of an assistant).
- (b) Bimanual laryngoscopy (explained in the video below by Dr. Levitan).
- (c) Advance the blade further, right up to the base of the epiglottis. Inserting the blade too shallowly will expose the epiglottis, but will leave it hanging downward and obscuring the larynx. If the blade is inserted further into the base of the epiglottis, it will then cause the epiglottis to flip up, exposing the larynx.
- (d) If the epiglottis is unusually long and/or floppy, it may hang down even with adequate placement of the blade. In this case, the blade may be advanced further to directly pick up the epiglottis (using the Macintosh blade like a Miller blade)(1).
Pearl #3. Use straight-to-cuff stylet shaping.
Pearl #2. What to do if the styletted endotracheal tube gets caught?
Pearl #1. How can you do a cricothyrotomy on a patient without a palpable cricothyroid membrane?
Need more Levitan? See this video on the EMCrit Blog.