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December M&M Tips

Teaching points summary:

* Testing the gag reflex is no longer thought to be an appropriate maneuver for assessing airway reflexes as it is neither sensitive nor specific and can provoke vomiting.

* Patients likely to desaturate quickly after pre-oxygenation include the obese, kids, pregnant women, and any patient with an oxygenation insult (pneumonia, pulmonary edema, asthma/COPD, pneumo/hemothorax, pulmonary contusion, etc).

* Although RSI with conventional laryngoscopy is safe and effective for most intubations, its appropriateness must be explicitly considered in every case. The less urgent the intervention, and the more difficult airway features present (difficult laryngoscopy, difficult bag-valve-mask, difficult cricothyrotomy) the more suitable is an awake technique.

* When in the midst of an intubation, the response to hypoxia is ventilation, not repeat laryngoscopy.

* Bag-valve-mask ventilation should routinely be performed with nasal and oral airways in situ as well as a two hands-down technique.

* If BVM ventilation is ineffective, the response should not be repeat laryngoscopy but rather the optimization of BVM ventilation. The most important interventions to perform are to re-position the patient, insert two nasal airways and an oral airway if not already placed, replace dentures if out, use a larger mask size, and change to a more experienced BVM operator. The use of airway adjuncts that may be blindly and quickly inserted, such as an LMA or combitube, is also appropriate to effect ventilation in an otherwise difficult to bag patient.

* Continuous capnography should be used as a tube confirmation technique when possible. If colorimetric capnography is used, a bright yellow response should be sought after six breaths.

* Have a low threshold to use the gum elastic bougie.

* Think of laryngoscopy as epiglottoscopy, as the purpose is to first control the tongue and then to find and control the epiglottis. Perform bimanual laryngoscopy by using your right hand to manipulate the thyroid cartilage to optimize glottic view.

* Patients being bagged with high FiO2 require surprisingly little ventilation to fully oxygenate. Bag slowly and gently to minimize gastric insufflation.

* For all intubations, consider using the intubation checklist, overflowing with handy reminders and pearls. Use the Sinai EM Updates page and click on “airway.” http://mssmem.com.

Process Results:

* The glidescope handle, previously behind a key, is now in an easily-opened drawer and should be immediately available when needed.

* Airway equipment, including difficult airway adjuncts and implements for performing awake intubation, will soon be organized on a cart so as to provide immediate and reliable access.

* Airway management strategies were reviewed this morning and residents were trained in the two-hands down method of bag-valve-mask ventilation.

Written by reuben

December 24th, 2008 at 11:48 pm

Posted in Airway,Pearls

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