# Intubation Tricks / Tips



## MCGLYNN_EMTP (Oct 8, 2009)

Hey,
I'm still a fairly new paramedic and I'll admit that I'm not perfect and I could use help on a few things from time to time.

I was just wondering if any of you had any tips / tricks that you use when intubating...or when you're having trouble intubating?
IV tips / tricks are welcome too....Hell..ANYTHING that can help a fresh paramedic is welcome!


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## SurgeWSE (Oct 9, 2009)

I'm sure you'll find some very useful tips/tricks of you search around.  As for me personally, I can recommend the following:

1. Find a blade you like.  With adults, I usually start with a Mac 4 or Wisconsin 3 depending on what's available and change if I need.  With kids, I go with the Broslow.

2. If it's not a trauma, use positioning in your favor.  A pillow or blanket placed under the shoulders to allow to better head positioning has helped me so often that I now shove one under there right off the bat on every tube.

3. Get your stuff ready before you start.  ALWAYS wear eye pro and face mask...cannot stress this enough (we aren't always good about this, but anyone who has had a GI blood rocket his them in the glasses will testify to its necessity).  Unwrap whatever device you're using to secure the tube, have your syringe ready, have your failed airway supplies standing by, etc.  Also if you use ETCO2 on your monitor, remember that it has a warm-up time on some monitors, so turn it on first.

4. Utilize other personnel at scene.  I take the tube I plan on using, check it, lube it, and hand it to my partner or lay it on the patient's chest.   Then I place the scope with my left hand and start with my right hand on their neck so I can do my own crichoid pressure and find my land marks.  Then I'll hand off crich. pressure to my partner, having them maintain the same placement I had.  Take the tube in right hand, pass it, inflate it, and confirm placement.

5. If it's bright and you're outside, have someone throw a blanket over you and the pt so the ambient light doesn't get in your way.

6. PRACTICE.  If you have a cadaver lab or operating room available, use it.  If not, use any different airway manikins you can find and any other available resources.  Doing 10-20 tubes a year will NOT allow you to become or stay proficient and it will not expose you to the variety of airway difficulties and different airways you will experience.


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## SurgeWSE (Oct 9, 2009)

As for IVs...

1.  Place the tourniquet and let their arm dangle, but don't put the tk on so tight that it starts to occlude arterial flow as well as venous.

2. Remember that their are plenty of places to look besides AC and hand.  Back of forearm, lateral/distal forearm (above radius), feet (careful in diabetics, but if it his the fan, veins are veins), upper chest (around clavicles etc.), EJs, etc.

3. If you need something in which to push meds and don't need to drop tons of fluids (or D50W), don't be afraid to downsize and go for less common places.  A #22 or #24 in the lateral thumb, the knuckle between the pinky and ring fingers, the anterior wrist (below the palm), the actual palm of the hand, scalps on kids, etc. will deliver your meds just fine.

4. Consider what will be done with your IV once you've finished transported.  If you patient has abdominal pain or a possible AAA or thoracic aneurysm, try to put a #20 or #18 high on their arm so your line can be used for a CT-Angio.

5. Like with Intubation, practice and more practice.  I've found IV arms to be pretty useless, but a few years in and you'll find that you've done it enough that you can get some kind of line, somewhere, on just about every patient you see.  That said, occasionally it just isn't going to happen. Remember that in a bad situation, you have IO or central lines depending on your protocols.


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## MSDeltaFlt (Oct 9, 2009)

From what Surge posted I agree... mostly.  #2 and #5 especially.

For #2.  We sleep on pillows for a reason.  Surgery uses those donut thingy's.  Again for a reason.  It will help you bring the airway into alignment.  If you don't have that, sitting cross-legged with one of your legs under the pt's head will do basically the same thing.  But unwise if the pt puked or is going to puke.

For #5.  There isn't a laryngoscope bulb made that is brighter than the sun.  Keep that in the back of your mind when tubing someone in their front yard after lunch.

I would, however, becareful (just be careful mind you) about finding one paticular blade you like.  As there are different sized and shaped people on this little blue ball, there are different sized and shaped airways.  There is also a reason why there different sized and shaped laryngoscope blades.  Get used to using them all.

Do not get into an intubation situation without your backup airways at the ready.  Treat them like condoms.  It's better to have them and not need them, than to need them and not have them.

Some more stuff.  If anyone says they never missed a tube, then they are either not as experienced as they say/think they are, they are lying.  It's OK to miss a tube every now and then, just don't lose the airway.  You have back ups for a reason.  Use them.

When it comes to IV's, get used to using your sense of touch.  *Feel* the veins.  One nurse, who I call a "big gun", told me, "If you can't feel it, don't stick it".

Also, get used to sticking enroute.  Make it a habit.

One last thing.  You can't teach experience.  Get out there and get some.  Welcome to the field and good luck.


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## Dwindlin (Oct 9, 2009)

MSDeltaFlt said:


> One last thing.  You can't teach experience.  Get out there and get some.  Welcome to the field and good luck.



Both had extremely good advice however the quoted I think is THE most important thing said.  Experience is king everywhere in medicine.


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## MCGLYNN_EMTP (Oct 9, 2009)

MSDeltaFlt said:


> Do not get into an intubation situation without your backup airways at the ready.  Treat them like condoms.  It's better to have them and not need them, than to need them and not have them.



Great way of comparison...and Thanks for all the pointers...I will deffinately keep these in mind


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## MasterIntubator (Oct 9, 2009)

Good stuff....  in addition to the above stated...

#1 tip.  Breathe for yourself, keep calm, don't rush, and fight the coffee hand type jitters.  If you rush, you will eventually will screw up, then you get frustrated... then you scream.

Find a handle/blade combination that you like.  Practice and practice.  Over and over.  Intubate your partner for fun. ( well... at least attempt  ).  Have that MSdelta back up, that you should feel just as comfortable with.

For the 90 degree setups that most all EMS have, try holding the handle in the 90 degree joint, with your palm resting just below the blade viewing area ( don't block your view ).  This sometimes helps with the over-doing the lifting, helps with wrist strain after awhile and some say they get better control of the system.  ( as opposed to having your hand on the entire upper handle. )

As you enter, s l o w l y  advance giving a lift to the tip of the blade allowing you to see LANDMARKS.  If you don't see any, relax the tip down, go further another half inch and repeat until you see landmarks.
Some of my cohorts do the opposite... they bury the tip to a suitable experienced depth, and slowly back out with lift until they see thier landmarks.

To eachs' own, you will find yours.  

Try different handles ( nothing wrong with using a peds handle on a #3 or #4 blade of your choice.

Now... this may stir debate ( but do as you are taught ), I have not bought into and never have.. with the vellecula vs blade deal.  I lift the vellecula with all blades so its never an issue.  Again... 20 some years of it, and that it was I have learned. 

If you are into having a set for yourself... do your homework.
I spent mucho $$$ on numerous styles of blades ( more than mac or miller ) and handles, as well as some unique demos to play with. 
My latest set up is a satin pediatric handle with an Grandview blade set and a 45 degree howland lock adaptor ( which are not that expensive ). 
The back ups are a HEINE flex-tip and standard fiber optic set of Satin FOCS Mac blades in case the grandview does not satisfy me.

Be aware.... not all the fiber optic systems are interchangeable.  The Rusch green line ( with the bulb in the handle ), is expensive, and the handles break often when dropped.

The FOCS fiber optic blades are meant to work with any standard handle ( without the light in it ).  Which means, you spend a bit more for the blade, but any 'ol $20 handle will work.
( why my choice?  Easy to clean, bulb is sealed back of the blade ( but replaceable ), does not get hot, and its bright )

( just options for the eager beaver out there )

May your adventures and daydreams drive your want to succeed.


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## VentMedic (Oct 9, 2009)

MasterIntubator said:


> ( why my choice? Easy to clean, bulb is sealed back of the blade ( but replaceable ), does not get hot, and its bright )


 
How do you clean your blades?


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## MasterIntubator (Oct 9, 2009)

cidex, then 5 min ultrasound.  I have used clorox as well.


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## MasterIntubator (Oct 9, 2009)

Ohh... gas sterilization in house via materials magmnt.


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## JeffDHMC (Oct 11, 2009)

Always always always make sure the adaptor is jammed into the tube. It's never a good thing when it comes off.


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## MCGLYNN_EMTP (Oct 12, 2009)

I hate when that happens


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## emtbill (Oct 12, 2009)

I would recommend getting the patient's mouth open as wide as possible before inserting the blade. On intubation mannequins I often find that there is plenty of room for the blade to be inserted into the vallecula without manipulation of the mannequin's mouth. On real people this usually isn't the case, and is why it's important to make sure you can fit at least a three finger width between the patient's hyoid bond and chin during pre-RSI physical inspection to predict a difficult airway.

Anyway, after padding the patient's shoulders and placing the head in the sniffing position, pull the chin down to open the mouth, and take your right thumb and pointer finger and place them in the rear of the patient's mouth with your thumb on the patient's top molars and pointer finger on the bottom. Push the patient's mouth open using a scissoring motion. You can then insert the blade with your left hand, sweeping the tongue to the left for easy visualization of the vocal cords.

Here is a good video illustrating what I'm talking about:
[YOUTUBE]http://www.youtube.com/watch?v=5J3J38se3TQ[/YOUTUBE]


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## MasterIntubator (Oct 12, 2009)

..... and that is how calm and easy they should be. They don't always.... but many do.  MMMmmm.... that video just... mmmmmm....  ohhhhh... sooo nice.

Gotta go...


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