Intubations this month: 30
Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations for July 2018. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.
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Focus on: Epiglottoscopy
These stills are taken from CMAC footage of a prehospital patient – see how lifting the epiglottis directly has improved the view of the tracheal opening.
You might remember this technique from our earlier video “Mac as a Miller”, which demonstrates how scooping the epiglottis with the Mac blade – as you would intentionally with the straight Miller blade – does not preclude intubation and may improve your chances in event of a grade II-III view.
As in our video focus section for May/June‘s clinical governance day, we were reminded that lubricating the laryngoscope blade can be particularly helpful for interhospital missions where patients often have very dry tongue mucosa from non-invasive ventilation or general dehydration. Intensivists present at CGD admitted they routinely lubricate a laryngoscope blade. We don’t think this point ever makes it onto an ‘airway assessment’ list but it should; keep it in mind. Here’s that double-learning-point video to remind you.
Trying to get a bougie to pass into the trachea can be a very frustrating experience. Practice can help – to aid us in identify when curving (or other manoeuvres to move the bougie tip anterior) are necessary, and to practice the ‘feel’ of rotation for moving the tip right to left.
Try practising laryngoscopy on a manikin and intentionally touching different parts of the laryngeal structures with your bougie tip to practice that control. Remember to practice with gloves & safety glasses on!
Video Focus on: the effects of blood and secretions
We discussed two videos. In the first, there are significant facial injuries. A gloved hand just visible providing good mouth opening – note how despite facial injuries, the larynx is quite identifiable and not flooded with blood.
In the second video, there are pooled airway secretions. You can see clear secretions filling the NPA visible in pharynx.
As mentioned in the May/June post, we carry a blue coudé tip bougie and a white straight bougie.
During this intubation, it was noted by the team member watching the screen (VL) that the approach of the white bougie caused a significant change in the screen image brightness, which dulled the view of the larynx in the background by comparison.
In the same patient the blue bougie had much less effect and the view of the larynx was maintained, allowing intubation.
Presumably this is the CMAC camera auto-adjusting for brightness in the visualised field on the video screen, so not an issue when using the CMAC for DL – but it is worth considering as a sudden reduction in illumination at the point of intubation could be most unhelpful when using the CMAC VL! We intend to discuss this with Storz, the manufacturer of the CMAC.
ELM obstructing the airway
In this video, a team member is providing external laryngeal manipulation in an attempt to improve the view at laryngoscopy which is released after bougie insertion. Note how on release of ELM, the cords appear to open wider. Care should be taken with any ELM (or cricoid, when used) to avoid closing the cords and making laryngoscopy more challenging.