# Intubation



## emtlady76877 (May 10, 2008)

I started my learning intubation yesterday; however, I am doing something wrong. I am not writing this post to start a big debate. However, I would like to ask: I need some pointers I see my land marks but for some reason everytime I end up in the stomach. What am I doing wrong? I know I have a lot to learn that is why I am asking.


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## emtlady76877 (May 10, 2008)

*Intubations*

some replys would be nice I'm just not trying to start an argument


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## JPINFV (May 10, 2008)

While I can't answer your question seeing as how I don't intubate, but expecting a reply after an hour and a half is a smidge inpatient. Give the board some time and I'm sure someone will be able to answer your question.


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## firecoins (May 10, 2008)

emtlady76877 said:


> I see my land marks but for some reason everytime I end up in the stomach. What am I doing wrong?


bend the tube.  Give a nive curve so it goes up into the proper area.


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## Ridryder911 (May 10, 2008)

make sure you are moving/sweeping the tongue to the side

now open the glottic view by pushing upward, lifting the handle of the laryngoscope as moving upward (not backwards) to point the end of the handle to corner of the room. 

As others described after seeing the vocal chords, pre prepare your tube by a slight kink or by having styllette in place. 

Expecting to be able to intubate after a few attempts is unrealistic. Just alike any other skill, it takes practice and repeated practice. 

Good luck..

R/r 911


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## Jon (May 10, 2008)

You say you see your landmarks. Are you seeing the vocal cords, or other parts of the airway anatomy?

The vocal cords are very high up, and difficult to see if you don't get enough retraction. Are you using a stylette? You might really need to aim higher with the tube.


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## emtlady76877 (May 10, 2008)

I do see the vocal cords, and I am using  a stylette.


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## Jon (May 10, 2008)

In that case... make an extreme curve... like a "J" and watch the cords as the tube passes through.


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## MSDeltaFlt (May 10, 2008)

Light does not bend in the air all by itself.  What I mean is, if you can see ALL of the landmarks, then you should be able to pass the tube.

It sounds like you're not keeping your blade hand in the same position all the while keeping your eyes on the landmarks as you pass the tube until it stops past the chords.  Be mindful of how your body is positioned as you are intubating.  Body mechanics plays a major role.

Translation: I think you're backing out too early.  Stay right there, whole entire body, blade hand, and all until that tube goes past the chords.

Intubating is not unlike starting IV's.  It's a skill that is easy to learn, hard to master.  Very few ever really master it.  Though you may have 15-20 secs to pass the tube, the second hand on your watch is ticking by slower than it feels.


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## triemal04 (May 10, 2008)

Small trick to help get a better view of the cords (and then follow everyone elses advice).  When using sellicks manuever, don't ask someone to do it for you and leave it at that.  Have them place their fingers on the crichoid cartilage, then put your right hand over theirs, manipulate until it's where you want it, and have them hold it in place.


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## el Murpharino (May 10, 2008)

Positioning plays a big part as well.  One pearl I picked up while taking an advanced airway class is to place a pillow or folded blanket under the occipital lobe of the head, and then perform your intubation.  This places the body into more of a sniffing positon, which helps to align the anatomy and make view of the landmarks easier.


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## VentMedic (May 10, 2008)

triemal04 said:


> Small trick to help get a better view of the cords (and then follow everyone elses advice).  When using sellicks manuever, don't ask someone to do it for you and leave it at that.  Have them place their fingers on the crichoid cartilage, then put your right hand over theirs, manipulate until it's where you want it, and have them hold it in place.



http://www.monroecc.edu/depts/pstc/backup/paraselc.htm



> The Sellick Maneuver is performed by applying gentle pressure to the anterior neck (in a posterior direction) at the level of the Cricoid Cartilage. The Maneuver is most often used to help align the airway structures during endotracheal intubation. *The real value of this procedure is often misunderstood and therefore, is often underutilized. The REAL value of the Sellick Maneuver is to provide a means to prevent gastric insufflation and vomiting during ventilations in an unprotected airway. *BLS and ALS medics can direct a member of the resuscitation team to provide this maneuver early and continually until a properly placed endotracheal tube has been inserted. Remember that aspiration pneumonitis has a high mortality rate and proper use of this method can minimize its occurance.


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## bonedog (May 11, 2008)

BURP rather than Sellick.

Use of a stylette with the hockey stick curve and push the tube off and through the cords. ( this can be accomplished by having some one grab the end of the stylette while you push the tube into the glottis, put a right angle in the end of the stylette, this create's a handle for your helper)


I have seen people who lack upper body strength place the occiput on their foot to reduce the weight of the head and body.

With out being with you it is difficult to understand where your problems are arising from. IF you are seeing the landmarks you should be able to perform the proceedure. 

Good luck


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## triemal04 (May 11, 2008)

Sellick's and BURP are getting to be used interchangeably nowadays; right or wrong, that's what it's developing into, depending on the school and instructor, area etc etc.  Like RSI; it may technically mean rapid sequence induction, but now it's mainly known as rapid sequence intubation.

Either way, BURP (back-up-right-pressure) is what I meant.


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## MSDeltaFlt (May 11, 2008)

Something else I've been thinking about.

You say you see the landmarks.  Do you see all of them at one time?  Do you see the epiglottis, the trachea, the vocal chords, the arytenoid cartilage, and the esophagus?

What a lot of people do, even the experienced providers, is hyperextend the neck.  What it does is make the trach more anterior than it really is.  It also makes it harder to put the tube.  The sniffing position is always the way to go as long as the pt is not in C-Spine precautions.

What they also do is lever the blade.  It is possible to lever the blade and still not touch teeth.  More people do this than is realized.  That will also make the trach more anterior, thus making it harder to pass the tube.  Add these two together, and you can see why some tubes are missed.

Body mechanics is key.  You must lift the whole blade upward at a 45 angle with the head in sniffing position.  

You might also try lowering the bed if possible utilizing your center of gravity; somewhere near hip level.  What this does is help you put your elbow at your hip, using your center of gravity, move your body slightly forward lifting the blade up at 45 degrees.  With a pillow under their head putting them in a good sniffing position, there is a chance you won't even need a stylette.  I'd still use one, though, but you won't need it.

Hope this helps.


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## VentMedic (May 11, 2008)

triemal04 said:


> Sellick's and BURP are getting to be used interchangeably nowadays; right or wrong, that's what it's developing into, depending on the school and instructor, area etc etc.  Like RSI; it may technically mean rapid sequence induction, but now it's mainly known as rapid sequence intubation.
> 
> Either way, BURP (back-up-right-pressure) is what I meant.



Time should be taken to understand the difference between the manuevers especially when you are still in training.  

The Sellick maneuver is backward pressure on the crichoid cartilage. It is used as a method to prevent regurgitation of stomach contents. 

BURP is used by exerting pressure on the thyroid cartilage. Positioning the thyroid cartilage backward, upward, and rightward is believed to improve laryngeal view with a laryngoscope. 

There are good and bad points to each of the maneuvers so it eventually becomes a matter of preference as you gain experience and your own comfort zone for intubation. 

We've already discussed the difference between Rapid Sequence Intubation and Rapid Sequence Induction.  It may be nit picking to some but not to legal eagles, researchers and those who do perform induction.


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## bonedog (May 11, 2008)

Hopefully these maneuver's are gone over in the OR with your anethetitist mentor. 

I know when I was shown the BURP it was relevant to having the lights turned on and there is the object you seek.

 I use the Sellick with gastric insuflation and when paralytic's are involved,the goal, keeping the gastric contents in place, also gives the added bonus of feeling the loss of muscle tone when the drugs take effect.

I also always use a stylette, not usually needed, however, does prevent time loss/re-insertion, if it is needed.


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## eggshen (May 11, 2008)

Whoever mentioned the sniffing position as it right on in my opinion. You will see a lot of medics extend the head, when they cannot see the cords they extend the head even more...and more and more. This actually buggers up the alignment you need to see the cords. Placing the patients auditory canal on the same plane as their sternal notch is the position you are looking for. 

Another trick is to make sure your tube/stylette are completly straight with a about a 40 degree anterior bend in the distal few cm of the tube. With the tube straight you decrease the cross-section you are looking down and are able to see the airway a little better as it not occluded by a big rainbow shaped tube.

You mentioned that you are seeing your anatomy. One thing to consider, and I'm not saying it's you, is that when you are not experienced at looking down necks the sides of a pryed open esophogus can resemble vocal cords. 

I hope some of this helps
Egg


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## Guardian (May 11, 2008)

emtlady76877 said:


> I started my learning intubation yesterday; however, I am doing something wrong. I am not writing this post to start a big debate. However, I would like to ask: I need some pointers I see my land marks but for some reason everytime I end up in the stomach. What am I doing wrong? I know I have a lot to learn that is why I am asking.



that's a pretty hummingbird


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## MasterIntubator (May 13, 2008)

A few things you can try.....  Try using a smaller handle - I traditionally use a peds handle, it feels better and handles better.

Sink your blade all the way back ( use care and advance it gently, sensitive mucosa back there ), then lift up and slowly slide it out as you watch.  This does a few things for me.... 1- often helps with the tongue prob, because the tongue follows the blade outward, giving you more visability.  2- lets you see the structures as they pop into view. 

Blankets under the shoulder blades and let the head rest hyperextended

Get an adjustable handle for better angles ( I use a Howland lock ) which gives you that 45 degree angle folks were talking about.

In a well ventilated patient, you have time. Take the time to do it right the first time ( oxygen desaturation is about 3-4 minutes ), so taking a minute to intubate isn't such a bad thing ( as many field providers tend to get excited and rush thru it, decreasing the beautiful world of statistics ) 

Don't take the Mac/Miller- vallecula thing verbatim.... if you are a mac person, shove that #4 in there and back out until you see the cords at 12 noon.  I know that is the way the texts preach and the manufacturers design thier equipment, but.... keep an open mind and an open technique.\
Many of my successes have been with a #4 mac on a peds handle and I could care less about the vallecula, I just move it out of the way.

Next time you try intubating, try these great suggestions folks are giving here.... one is bound to help you, and you will stick with the one that gives you great success.


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## emtlady76877 (May 15, 2008)

*Intubations*

Thank you,
        I listened to your pointers and to a mac I intubated both the adult & the baby manicans today.


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