Digital (finger/touch) Intubation

[ambodriver]

I have never done a digital intubation on anything but a dummy. I wouldn't see myself doing it--I'd rather throw a combitube in rather then lose my fingers in a entrapped person. Just my two cents.

[VentMedic]

No, I haven't. I would likely cric someone if my only other option was digital intubation.

If you are considering digital intubation, you should have some access to the cords and therefore it would be very difficult to justify doing a cric.

Digital intubation could be considered in dire situations where:

1. for some reason lack the equipment,

2. have equipment that does not work,

3 positioning of provider and patient might be an issue

4. there is a deformity either due to nature or injury that hinders the use of a regular laryngoscope scope or

5. using the BVM is no longer or not an option.

Digital intubation has it place but less often now in the adult world since there are LMAs, King tubes and even the OPA that can be used if ETI is not immediately possible. NTI may even be a consideration but only not always the best. Of course the Tomahawk method should still be a technique taught as an option as well.

However, for neonates and pediatrics, digital intubation may be a necessary option. Any RRT or RN that does intubation in the hospital or on transport has probably been taught this procedure if they work in the neo/pedi population. That includes the big male nurses and RRTs with large hands and fingers. It does not matter what size your fingers are, you learn to perfect the technique. Your technique may vary slightly from someone who has tiny hands but the goal is the same. Most of the procedures done in that population require a delicate touch which can be acquired through practice and a desire to work with infants as a health care provider. That should also include the Paramedic.

Most pediatrics can be effectively maintained with the use of an OPA and BVM which is another technique that should be taught well, but often isn't, since pedi ETI is now removed from the protocols of several EMS agencies. But, they also seem to forget to teach OG/NG placement which then only gives you limited bagging time before the abdomen takes over the tiny chest cavity and the BVM becomes useless where even a tube placed now will be ineffective until the belly can be decompressed.

There will also be infants and pediatrics that have deformities either present at birth which have yet to be repaired or may be with them for the rest of their life. This might include some cleft palate malformations or even the Down's Syndrome child whose tongue may require some manipulation. If a neonate is being born with a known congenital defect like a diaphragmatic hernia, the intubator can not dick around looking for another scope if the one he/she is using fails. That baby must be intubated and the BVM is not an option.

There was also a discussion here a few months ago where someone said they used or saw/heard someone use an adult MAC 4 in the field in an attempt to intubate a baby. I would rather use my fingers if I had no other appropriately sized equipment and very little experience intubating babies before I would use a large piece of metal and risk damaging the airway to where a cric might then be a necessity or the blood from the traumatic attempt would asphyxiate the baby. Someone with a thousand infant tubes to their credit might be able to pull off just about anything with any type of equipment but then they are intimately familiar with the anatomy of a baby.

Thus, learn, practice and perfect as many different intubation techniques as you can for every age group. Know how to score a difficult airway to help you choose the correct device and technique for the patient. Do not become one that says "I always use curved because I like it better" which is something that is too often learned from the classroom by playing with the manikins under poor supervision or listening to instructors who know little about educating for airway emergencies and spout off their own style as "always worked for me" rather than explain the purpose of each blade and/or method.

Of course there are a few words of caution no matter what technique you use. Even if you have given a paralytic to a patient, teeth or no teeth, have a bite block in place preferably on both sides of the mouth so you don't get taken by surprise if you plan on putting your fingers into someone's mouth. This can include trying to get a better grip on a FBO. Even those without teeth can leave a nasty bruise on your finger.

Edited March 26, 2010 by VentMedic

[Arctickat]

I've done it twice, both on entrapped patients and prior to blind insertion airways being approved for use in our area. One tool I found useful, and still use is a dental retractor designed to hold the jaws open. Dentists use them to protect against someone biting down on their fingers. It is inserted into the mouth, then locks automatically as they are opened. Attached is a picture of the tool.

[KosherMedic]

If you are considering digital intubation, you should have some access to the cords and therefore it would be very difficult to justify doing a cric.

Thanks for your informative post.

If my only option was digital intubation I would prefer a cric. Of course, it all depends on the situation. We should only cric people who we cannot intubate another way and have low oxygen saturation. I envision a situation where, as a previous poster considered, a patient is in a twisted hunk of metal and very seriously hurt. This person likely has a decreased LOC and shock, so I need to capture their airway. Yes, I could try to utilise a bougie tube to accomplish a digital intubation and I might. However, I wouldn't hesitate to move to a cric if the situation warranted it.

I haven't done any digital intubations other than on mannequins. I also haven't done any crics. When it comes to the two procedures I would be more comfortable doing the cric, as I am much more confident with that procedure. This discussion has shown me that I should study the digital intubation procedure more so I can become more comfortable with it.

On a related topic, what do you think of "The Manual of Emergency Airway Management" by Walls?

[croaker260]

Princess, I would never try and speak for someone else, but I believe croaker is speaking of a technique called the "tomahawk" method around here. Basically, it can be used when you are either behind the pt. ie: they are up against the windshield, and the traditional method of intubation is impossible or you can't get to the airway do to the position of the pt.. I could also be totally off base here though . If you ever have the opportunity to attend "The Difficult Airway Course" I highly recommend it. You will learn some techniques which will improve your intubation success rate.

No, I have never digitally intubated a pt. in my short career. I don't think I would unless it was a similar situation as Dwayne described. However, one never knows which sort of situation they will be placed in from day to day, so I can't say I never would.

Jake is correct. Tamahawk = Sky-hook = Pick-ax. Different names, same approach.

[ambodriver]

Thanks for your informative post.

If my only option was digital intubation I would prefer a cric. Of course, it all depends on the situation. We should only cric people who we cannot intubate another way and have low oxygen saturation. I envision a situation where, as a previous poster considered, a patient is in a twisted hunk of metal and very seriously hurt. This person likely has a decreased LOC and shock, so I need to capture their airway. Yes, I could try to utilise a bougie tube to accomplish a digital intubation and I might. However, I wouldn't hesitate to move to a cric if the situation warranted it.

I haven't done any digital intubations other than on mannequins. I also haven't done any crics. When it comes to the two procedures I would be more comfortable doing the cric, as I am much more confident with that procedure. This discussion has shown me that I should study the digital intubation procedure more so I can become more comfortable with it.

On a related topic, what do you think of "The Manual of Emergency Airway Management" by Walls?

i think a lma/combitube would be more effective in these situations besides going straight for the cric. Especially where space and access might be an issue. That's just me though.

[croaker260]

i think a lma/combitube would be more effective in these situations besides going straight for the cric. Especially where space and access might be an issue. That's just me though.

The LMA was never intended by the original designer for a rescue airway, but it may serve. Combitube I like better for this situation, but it also has limitations.

Having done crics, I can say that the worse situation I can imagin trying to do a cric (other than prone) would be sitting in a car with poor lighting, inability to extend the neck, and limited access to the patient. WOuld I do it if I had to, of course. But chosing a cric over an attempt at a digital...nahh probably not. Remember that a cric is for when everything else goes horribly wrong...not something to be taken likely. I have seen, and I am sure Vent has as well...crics gone wrong.

A cric is something we should move promptly and decisively to when needed, and idealy in less than 10 minutes from 1st ETT attempt...(and refractory to BVM, rescue airway, etc) but not recklessly. Far less complications with a rescue airway, or a good old fashioned ETT (placed however you place it) than a cric.

Vent, very informative post on pediatric digital ETT. Kudos. Myself...I have never had to do that, and honestly probably wouldnt have thought of it. But...I will tuck that away in my mental bag of tricks. Thanks. I have found most of my tubes in small children, even those with some life left in them, easier than some adults. But alas we trained on cats in school...something you dont see anymore.

[VentMedic]

This is a decent ppt of infant intubation and some of the situations one could come across.

http://www.pediatrics.emory.edu/ccm/lectures/files/The%20Neonatal%20Airway.ppt

Meconium is also something one should be aware of if there is a chance you might happen across someone giving birth. One should check their equipment and review the procedure with their current partner so there will be no fumbling when seconds count. Even in controlled situations, we take the new (experienced but new to L&D or NICU) RRT or RN after their NRP class and have them spend a day just getting the hang of neonatal resuscitation with procedures repeated over and over which includes the meconium aspirator, suction and ETI. It generally takes an RRT or RN at least 10 - 20 intubations in the NICU before they are allowed to be part of the L&D resuscitation team. Unfortunately Paramedics do not get that luxury and must find at least an infant manikin to practice on. Fumbling can sometimes be excused but not if it is because you are not familiar with your equipment and the basics of the procedure.

[KosherMedic]

i think a lma/combitube would be more effective in these situations besides going straight for the cric. Especially where space and access might be an issue. That's just me though.

I've been taught to go for an alternative airway at the same time I go for the cric. Basically, my partner would try something like a Combitube and I would try a cric. Whoever wins the race gets to help the patient get the oxygen they desperately need. I don't think it's a good idea to try a Combitube and then try a cric. My BLS partner can do a Combitube, so it makes sense that they try that while I try for a cric.

[VentMedic]

I've been taught to go for an alternative airway at the same time I go for the cric. Basically, my partner would try something like a Combitube and I would try a cric. Whoever wins the race gets to help the patient get the oxygen they desperately need. I don't think it's a good idea to try a Combitube and then try a cric. My BLS partner can do a Combitube, so it makes sense that they try that while I try for a cric.

The point here is that if you have a path from the mouth to the cords to where either digital intubation or a CombiTube could be done, you would not be justified in doing a cric. Just be cause you can isn't always the best route. Alternative airways can be a stable airway until the hospital is reached to where more equipment is available to intubate the patient without cutting open their throat. If a ground EMS crew has established a Combitube, King or even an LMA to where there is evidence of adequate ventilation and oxygenation, very few flight crews would ever consider changing out for an ETT or doing a cric. Even in the hospital, we wil have all of our ducks in a row before we put that alternative airway. I have also used a BVM for very long periods of time with no problem while waiting for the right equipment for a difficult airway.