Digital (finger/touch) Intubation

[KosherMedic]

Please forgive me if I haven't been clear. I was talking about a patient who I needed to "help ... get the oxygen they desperately need". A patient who cannot be ventilated successfully with a BVM or intubated, yet is unconscious is in need of an immediate airway. My point was that I would attempt the Combitube and cric at the same time in a patient who I was not able to intubate and was in desperate need of an immediate airway. This idea of attempting to use a device like the Combitube at the same time you attempt a cric is taught in "The Manual of Emergency Airway Management" and I think it makes sense.

http://volusia.org/ems/COMPLETE%20RSI%20INSERVICE.pdf

Thanks again for your response and the learning opportunities.

[croaker260]

Please forgive me if I haven't been clear. I was talking about a patient who I needed to "help ... get the oxygen they desperately need". A patient who cannot be ventilated successfully with a BVM or intubated, yet is unconscious is in need of an immediate airway. My point was that I would attempt the Combitube and cric at the same time in a patient who I was not able to intubate and was in desperate need of an immediate airway. This idea of attempting to use a device like the Combitube at the same time you attempt a cric is taught in "The Manual of Emergency Airway Management" and I think it makes sense.

http://volusia.org/ems/COMPLETE%20RSI%20INSERVICE.pdf

Thanks again for your response and the learning opportunities.

I'm thinking vent may or may not be able to back me up on this, but here are my thoughts....

I know that the concept of using a rescue airway or attempting ETT at the same time as cricing seems like a good use of limited time, and in some cases it would be, such as laryngeoscopy while attempting a retrograde ETT....

But I also know that in the case of a fractured larynx you must intubate PAST the fracture with an ETT. And the airway pressures for a supra-glottic airway are even higher. Therefore I think that altering the integrity of the lower airway with an attempted cric, and using a combitube or a LMA (or a king, PTL, EGTA, what ever) instead is a recipe for (at the least) SQ air; if not very poor ventilation or even complete airway obstruction. The airway pressures for a supra glottic airway must by nature be higher than that of an ETT to provide effective ventilations, so the concept of doing both seems like something that "sounded good at the time" but actually isnt.

At least if you use the ETT, you an advance it past the incision and still ventilate until the surgeon can repair the incision (this is what a friend had to do with a Fx larynx one time on a ped)

Finally, if a combitube (or what ever) was a realistic consideration (or BVM) then I would have some strong thoughts about even attempting the cric. IMHO, the cric is strictly reserved for the known CICV situation.

I hope this is making sense....good discussion.

Edited March 29, 2010 by croaker260

[KosherMedic]

I'm thinking vent may or may not be able to back me up on this, but here are my thoughts....

I know that the concept of using a rescue airway or attempting ETT at the same time as cricing seems like a good use of limited time, and in some cases it would be, such as laryngeoscopy while attempting a retrograde ETT....

But I also know that in the case of a fractured larynx you must intubate PAST the fracture with an ETT. And the airway pressures for a supra-glottic airway are even higher. Therefore I think that altering the integrity of the lower airway with an attempted cric, and using a combitube or a LMA (or a king, PTL, EGTA, what ever) instead is a recipe for (at the least) SQ air; if not very poor ventilation or even complete airway obstruction. The airway pressures for a supra glottic airway must by nature be higher than that of an ETT to provide effective ventilations, so the concept of doing both seems like something that "sounded good at the time" but actually isnt.

At least if you use the ETT, you an advance it past the incision and still ventilate until the surgeon can repair the incision (this is what a friend had to do with a Fx larynx one time on a ped)

Finally, if a combitube (or what ever) was a realistic consideration (or BVM) then I would have some strong thoughts about even attempting the cric. IMHO, the cric is strictly reserved for the known CICV situation.

I hope this is making sense....good discussion.

I'm not talking about EET at the same time as a cric. I'm talking about a patient who NEEDS an immediate airway, an ETT is not possible, and their oxygenation cannot be maintained with a BVM. Dr. Walls recommends going for an alternative airway at the same time as a cric. Please, check out "The Manual of Emergency Airway Management". Check out the "Failed Airway Algorithm" on page 18ff.

http://books.google....page&q=&f=false

Not everyone will agree with the recommendations contained in "The Manual of Emergency Airway Management", but many in the EMS world follow these recommendations which are based on pre-hospital research.

Edited March 30, 2010 by KosherMedic

[Medic One]

LOL....good topic but I wouldn't do it unless I had fingers like John Holmes!!

[croaker260]

I'm not talking about EET at the same time as a cric. I'm talking about a patient who NEEDS an immediate airway, an ETT is not possible, and their oxygenation cannot be maintained with a BVM. Dr. Walls recommends going for an alternative airway at the same time as a cric. Please, check out "The Manual of Emergency Airway Management". Check out the "Failed Airway Algorithm" on page 18ff.

http://books.google....page&q=&f=false

Not everyone will agree with the recommendations contained in "The Manual of Emergency Airway Management", but many in the EMS world follow these recommendations which are based on pre-hospital research.

I am familier with the worthy text by Walls and the algorythm, but I think you misunderstand me. I was using the example of an ETT as a reasons why doing a cric and an ETT simultanously is counter productive, and comparing the ETT to the supraglottic airways (wich use higher airway pressures) to explain that doing a cric AND a supraglottic airway simultanously is even more counter productive.

In short, the alteration of the integrity of the lower airway will render the supra-glottic airway ineffective. But if you are going to do both a cric and a supraglottic airway, then focus your rescources and just do the cric, because you will have the first incision before you get the supra-glottic airway out of the package. Again, not what I would reccommend, but once you cut into the trach, the supra-glottic airway becomes useless.

Do the supraglotic airway de jour quickly, and if it is ineffective, or contraindicated, either BVM them or if that is not an option, then chose to do the cric... quickly.

That is my point.

Thank you.

[VentMedic]

Let me spring a few more airway situations on you which is now seen more often in the field for EMT(P)s as there are more subacute facilities and home care patients with tracheotomies and tracheostomies or stomas.

When you pick up a "trach patient" do you assume it is a "trach" like the one shown in the EMT(P) textbooks or do you examine for brand, model, size and if it has a 15 mm adapter?

What if you have a patient with a false tracted trach?

Do you know how to recognize it and how long would you attempt to recannulate (with another trach or ETT) before you moved to oral intubation?

What if the trach was for tracheal stenosis above the trach site?

Are you familiar with Blum-Singer (speaking) valves in stomas? Or, the fistula that may exist between the trachea and esophagus for speaking valves of laryngectomy patients?

Can you immediately recognize a flesh colored stoma covering on a patient? This is a good mall people watching activity.

These patients may be young and active. They may be in biking or motor vehicle accidents and anywhere else that you would not expect to be faced with an alternative airway situation.

BLS: How do you manage the airway of a stoma patient? Sidenote: a tracheostomy/stoma may be found in pediatric patients who are in long term care and/or vegetative states to prevent aspiration.

What about all the numerous tracheotomy/tracheostomy devices that don't have a regular 15 mm adapter for the BVM? Montgomery tubes, Singer laryngectomy tubes and Shiley trachs missing their inner cannulas are examples of this.

Has anyone seen an innominate artery blow? Was this discussed in your cricothryoidotomy or trach class?

Reconstructive surgery and/or radiation may make land marks difficult to identify if you do need to perform a cricothryoidotomy.

Some interesting websites:

Prostetic speaking valve and stoma/fistula coverings

http://www.google.com/imgres?imgurl=http://www.epithesen.com/images/trach6.jpg&imgrefurl=http://www.epithesen.com/engl/tracheostoma.htm&h=283&w=368&sz=18&tbnid=BTBikyToolDgGM:&tbnh=94&tbnw=122&prev=/images%3Fq%3DBlom%2Bsinger%2Bvalve&hl=en&usg=__kBol3Gh-SpoB1ctYsCvxWM5n45o=&ei=sW-yS9GSOoyOswOUl6DMAw&sa=X&oi=image_result&resnum=10&ct=image&ved=0CCcQ9QEwCQ

Speaking valve for laryngectomy patients

http://img.medscape.com/pi/emed/ckb/otolaryngology/834279-883689-33.jpg

Voice restoration for laryngectomy patients and the founders of the technology. (Some great information on this website especially under Educational Resources.)

http://www.inhealth.com/Blom-Singer_30years.htm

Larygectomy products and literature

http://www.inhealth.com/literature.htm

Montgomery Tubes (note that some look like dry wall hangers and may have been surgically placed.)

http://www.bosmed.com/airway-management/montgomeryr-cannula-system.html

These are just a few things to read about. RTs and ENTs get called almost every day to the ED by the ED doctors to identify and manage a funky looking device sticking out of someone's throat that was placed for some special reason by a Specialist. "Trach" is a catch all term but may not be the appropriate one to use when giving report. Others may "assume trach" and be caught off guard in an emergency by a specialized device.

Edited March 30, 2010 by VentMedic

[KosherMedic]

I am familier with the worthy text by Walls and the algorythm, but I think you misunderstand me. I was using the example of an ETT as a reasons why doing a cric and an ETT simultanously is counter productive, and comparing the ETT to the supraglottic airways (wich use higher airway pressures) to explain that doing a cric AND a supraglottic airway simultanously is even more counter productive.

In short, the alteration of the integrity of the lower airway will render the supra-glottic airway ineffective. But if you are going to do both a cric and a supraglottic airway, then focus your rescources and just do the cric, because you will have the first incision before you get the supra-glottic airway out of the package. Again, not what I would reccommend, but once you cut into the trach, the supra-glottic airway becomes useless.

Do the supraglotic airway de jour quickly, and if it is ineffective, or contraindicated, either BVM them or if that is not an option, then chose to do the cric... quickly.

That is my point.

Thank you.

Why would the Paramedic cut into the neck of the patient if his EMT partner got the Combitube in place and was successfully ventilating the patient? He wouldn't. The whole point of them trying their interventions at the same time is to increase their chances of getting an airway in a patient who is suffocating and terribly injured.

[KosherMedic]

Continued...

Walls says that a patient like that needs a cric. However, if your partner manages to get a supraglottic airway in place first then that should work fine.

"On your mark, get set, GO!"

Whoever gets their airway intervention first causes the patient to win and their partner has to buy lunch.

Does this make sense to you? I think it makes sense. Concurrent activity. Why should the EMT sit around and watch the Paramedic prep for a cric when they can be trying a supraglottic airway?

LOL....good topic but I wouldn't do it unless I had fingers like John Holmes!!

Haha... nice. I'll pretend that I don't know who he is.

But if you are going to do both a cric and a supraglottic airway, then focus your rescources and just do the cric, because you will have the first incision before you get the supra-glottic airway out of the package. Again, not what I would reccommend, but once you cut into the trach, the supra-glottic airway becomes useless.

Do the supraglotic airway de jour quickly, and if it is ineffective, or contraindicated, either BVM them or if that is not an option, then chose to do the cric... quickly.

That is my point.

Thank you.

To add...

All things being equal, I don't think that I would be dissecting to the cric membrane before my partner has the supraglottic airway out of the packaging. I would be examining the patient's neck for contraindications to a cric, landmarking, prepping the skin, taking the scalpel out, and rechecking my landmarks carefully. I imagine that my partner would have tried the supraglottic airway by then. If they failed I would incise the area.

And, just so you know, the scenario I am discussing is one where ETT and BVM have failed to oxygenate the seriously injured and unconscious patient who is trapped in a vehicle. Walls does not recommend the use of a supraglottic airway in a patient like this unless it is done while a cric is being readied. As a Paramedic, I would not waste my time on a supraglottic airway that my capable EMT partner is able to utilise.

Edited March 30, 2010 by KosherMedic

[croaker260]

Why would the Paramedic cut into the neck of the patient if his EMT partner got the Combitube in place and was successfully ventilating the patient? He wouldn't. The whole point of them trying their interventions at the same time is to increase their chances of getting an airway in a patient who is suffocating and terribly injured.

I guess we have different techniques of doing these proceedures.

If both Provider A reached for the blade/tube and Provider B reached for the combitube at the exact same time, then my money is on the incision being made before combitube cuff inflation and the first ventilation. Hence my argument that truely doing them simultanously is less than optimal.

But then again, perhaps we are just visualizing two different sequence of events, which must be the case. Now if you are argueing for "prepping" for a cric while your partner does/attempts the rescue airway, then I have no problem. But I was invisioning the truely simultanous attempts like they used to teach with retrograde intubation....and IMHO, I can cut the neck (and have) pretty quick.

[VentMedic]

If the ETT can make it through the cords and you still have a problem oxygenating and/or ventilating, a cric may not make a difference. It is time, or should have already been done, to check chest wall integrity and restrictions. This may apply for the BVM and any supraglottic devices as well. Haste may make waste without examining all the possibilities. Some narrow their focus too much to where they miss the bigger picture.

Also, as the higher patch on scene, I may want to be sure there is not a simple reason for the failure of a BVM or supraglottic device done by an EMT before I do a cric. This is not intended to offend the EMT. However, in reality few get little more than a couple hours of instruction and their only chance to place it is on a manikin. As well, most states that do allow EMTs to place a supraglottic device, the patient must be in a code situation or dead.

Sometimes something much simpler than a cric, even if it is a "BLS" or EMT skill, can be used to maneuver the anatomy of the upper airway to where effective ventilation can be achieved. I would not discount any form of airway management whether it is labeled BLS or ALS. It also only takes a few seconds to examine the upper airway with a quick look at the anatomical structures and another quick check of the chest wall to see what you can expect especially once positive pressure is applied. In an MVC, you may also have to prep the chest for a needle or a tube depending on your protocols.

Edited March 30, 2010 by VentMedic