Rural Emergency Room Simulation Teaching and Education Resource

QUESTION: In the pictures above, can you identify the 'novice' laryngoscopists from the 'experienced' laryngoscopists?
ANSWER: see the bottom of this page.

This page covers the 'infraglottic' airways which are either Endotracheal Intubation or  Emergency Surgical Airway (ESA) aka Cricothyrotomy.

The Power  Point below covers the approach to intubation in general and then covers the 'surgical airway' (Cricothyrotomy).
Next is a MSWord document entitled "Intubation checklist" that is from Dr. Reuben Strayer's web site  This is a VERY comprehensive and excellent checklist for intubation and highly recommended for review.
There are then 4 videos below. 
The first (DL video) is a general but very complete overview of Direct Laryngoscopy in general.  Duration ~ 15 minutes.
The second video is a short video by Reuben Strayer on DL versus VL.
The third is a cadaver demonstration of a 'scalpel, finger, bougie assisted cricothyrotomy'.
The fourth is a youtube video of a bougie-aided cric on a live patient.

Some Summary Points which may not be that apparent in the Power Point:
1. Supplemental Oxygen via nasal cannula (high flow) WHILE intubating has  been recommended as a way to prevent hypoxia during intubation. In fact at the September 28 rounds it was discussed.  However there was a study published in April 2015 in Intensive Care Medicine looking at this. They compared pre-oxygenation with 4 minutes of either 15 lpm mask flow versus high flow (60 lpm) nasal cannula which was then continued during the intubation. The rates and degree of desaturation during intubation were the same - ie high flow nasal oxygen during intubation does not in fact decrease the incidence of desaturation. 
2.. Always have a plan!  What you don't want to get in to is the scenario of 'can't intubate, can't ventilate' and you can't think of what to do next.
3. If you fail in the first intubation, try again, but try something different - ie head position, different size blade, different scope etc. but don't simply try again doing the same thing. You are bound to fail a second time!
4. Crics are easier than you think and way easier than the way they were taught in the past!

Airway 2.pptx Airway 2.pptx
Size : 3000.603 Kb
Type : pptx
Strayer Intubation checklist.doc Strayer Intubation checklist.doc
Size : 1340 Kb
Type : doc
DL video.mp4 DL video.mp4
Size : 25159.022 Kb
Type : mp4
Scalpel Finger Bougie II-SD.mp4 Scalpel Finger Bougie II-SD.mp4
Size : 5861.806 Kb
Type : mp4

Do Novices and Experts Hold a Laryngoscope Differently?
Can J Anaesth 2014 Dec. R. Eleanor Anderson, MD and Calvin A. Brown, III, MD, FAAEM

Yes, and it's all in the grip.
Direct laryngoscopy is a complex skill that requires both practice and proper instruction to master; however, specific teaching on handle grip and angle varies. A handle angle of 45° from horizontal is commonly taught as the best laryngoscope position for obtaining an optimal glottic view.

To study differences in technique between expert and novice laryngoscopists, researchers took photographs during routine intubations of elective surgery patients (22 experts) and mannequins (22 experts and 21 novices). All intubations were performed in full sniffing position with a Macintosh size 3 or 4 blade. Images were acquired at the point of maximal glottic exposure. Novices were medical students beginning an anesthesia rotation, and experts were attending anesthesiologists or senior anesthesia trainees (PGY-4 or higher). When intubating patients, experts used a handle angle of 23.7° — significantly less than 45°. During mannequin intubations, the average angle used by experts and novices did not differ significantly (26° vs. 31°).

Compared with novices, experts gripped the handle closer to the hinge, held the device in the fingers rather than the palm, and used a greater mean eye–scope distance. Experts did not change their technique when intubating mannequins versus patients.

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