10 Rules For Approaching Difficult Intubation

[Carlos Danger]

10 Rules For Approaching Difficult Intubation

A good basic review. Clearly intended for the in-hospital audience, but I think it's worth the read for anyone who intubates.

I think you need to create an account to see the article.

 

[VentMonkey]

Was able to view without creating an account. Thanks for the share.

 

[Aprz]

This has been on my mind a lot lately. My last three tubes, I failed. The last attempt was heart breaking for me since I had a CLS grade 1, admired it, and before I put the tube in, it disappear. After trying to have a firefighter do Sellick's maneuver several times, I decided to redo the attempt, but the best I could get was a CLS grade 3 (could only visualize the epiglottis). As I fail more, I have been thinking more and more how to improve my intubation skill. Where did I go wrong?

I remember on the first recent failure I had, I had to stop 2 times to tell fire not to stop CPR while I attempt intubation. They were trying to be nice, but I prioritize compressions over intubation. When I finally proceeded, they dummies decided to slide the scoop under the patient as I had the laryngoscrope in the mouth. WTF? I also hate that you can be 10 seconds in and people start asking "Do you see anything?" So you think that it is OK to slide a scoop under the patient and talk to me as I intubate, but that compressions should stop? I've made it a point to lay down some ground rules (don't stop CPR, not even for breaths, don't talk to me, and don't move the patient as I intubate) before proceeding with intubation.

On the same call, I had decided I'd be OK using fire equipment since the last few arrest I did that and was OK. On that call, they ONLY had a size 4 mac AND no bougie. I realized they had no bougie (required for us to use on all tubes in our county), I had my partner run back to the ambulance to grab it, I then checked the blade, and realized it a size 4 only. I usually intubate with size 3. I decided to proceed with the size 4 instead of making my partner run back. I now 100% bring my stuff in (we are suppose to use fire stuff, but I felt that set me up for failure).

Anyways, I hope my next tube will go well. It is unfortunate that I had so many failures. It has been bothering me. Up until recently, my success rate was high, so I don't know why I feel like I am struggling, if I am working myself up, but I do feel like I am usually calm and methodical. I am in no rush on cardiac arrest since I do not consider the the tube to be the priority and I do not consider cardiac arrest load and go like how fire treats it (I dunno why they always want to immediately transport a working arrest..). I've been volunteering to do the tube too and let the fire/medic continue running the code since they are usually first on scene anyways. Sometimes I regret that too (I had one where I focused on the airway, they wanted to load and go, I didn't protest, we left scene quickly.... minutes on scene only.... he gave report how they didn't do dialysis that day... and I was just.... we never gave Calcium... we should've done that instead of load and go... ugh!!!).

 

[RocketMedic]

This has been on my mind a lot lately. My last three tubes, I failed. The last attempt was heart breaking for me since I had a CLS grade 1, admired it, and before I put the tube in, it disappear. After trying to have a firefighter do Sellick's maneuver several times, I decided to redo the attempt, but the best I could get was a CLS grade 3 (could only visualize the epiglottis). As I fail more, I have been thinking more and more how to improve my intubation skill. Where did I go wrong?

I remember on the first recent failure I had, I had to stop 2 times to tell fire not to stop CPR while I attempt intubation. They were trying to be nice, but I prioritize compressions over intubation. When I finally proceeded, they dummies decided to slide the scoop under the patient as I had the laryngoscrope in the mouth. WTF? I also hate that you can be 10 seconds in and people start asking "Do you see anything?" So you think that it is OK to slide a scoop under the patient and talk to me as I intubate, but that compressions should stop? I've made it a point to lay down some ground rules (don't stop CPR, not even for breaths, don't talk to me, and don't move the patient as I intubate) before proceeding with intubation.

On the same call, I had decided I'd be OK using fire equipment since the last few arrest I did that and was OK. On that call, they ONLY had a size 4 mac AND no bougie. I realized they had no bougie (required for us to use on all tubes in our county), I had my partner run back to the ambulance to grab it, I then checked the blade, and realized it a size 4 only. I usually intubate with size 3. I decided to proceed with the size 4 instead of making my partner run back. I now 100% bring my stuff in (we are suppose to use fire stuff, but I felt that set me up for failure).

Anyways, I hope my next tube will go well. It is unfortunate that I had so many failures. It has been bothering me. Up until recently, my success rate was high, so I don't know why I feel like I am struggling, if I am working myself up, but I do feel like I am usually calm and methodical. I am in no rush on cardiac arrest since I do not consider the the tube to be the priority and I do not consider cardiac arrest load and go like how fire treats it (I dunno why they always want to immediately transport a working arrest..). I've been volunteering to do the tube too and let the fire/medic continue running the code since they are usually first on scene anyways. Sometimes I regret that too (I had one where I focused on the airway, they wanted to load and go, I didn't protest, we left scene quickly.... minutes on scene only.... he gave report how they didn't do dialysis that day... and I was just.... we never gave Calcium... we should've done that instead of load and go... ugh!!!).

California?

 

[Aprz]

California?

Pfff.... Of course, lol.

 

[VentMonkey]

@Aprz it seems as though a lot of what you've described has stemmed from either failing to prepare, and/ or your relationships with your areas fire departments. I fail to see how the state itself is relevant, other than making a stronger case for de-emphasizing routine ETI for all ground paramedics in California.

In my area, if there is no SGA in-place by fire, most ground paramedics don't seem much more comfortable. To me it is extremely evident that the lack of training (in general) for this state has long shown a reason for the ground paramedic's ability to maintain this questionably critical skill. If so, and this is what yourself and @RocketMedic were referring by referring to the state itself, then here I would very much agree.

Aside from what Jarvis has his folks do, I am unfamiliar with what the general success rates for paramedics in Texas, let alone their ongoing continuing education consists of. I would imagine it varies from county to county.

 

[Aprz]

@Aprz it seems as though a lot of what you've described has stemmed from either failing to prepare, and/ or your relationships with your areas fire departments. I fail to see how the state itself is relevant, other than making a stronger case for de-emphasizing routine ETI for all ground paramedics in California.

In my area, if there is no SGA in-place by fire, most ground paramedics don't seem much more comfortable. To me it is extremely evident that the lack of training (in general) for this state has long shown a reason for the ground paramedic's ability to maintain this questionably critical skill. If so, and this is what yourself and @RocketMedic were referring by referring to the state itself, then here I would very much agree.

Aside from what Jarvis has his folks do, I am unfamiliar with what the general success rates for paramedics in Texas, let alone their ongoing continuing education consists of. I would imagine it varies from county to county.

I honestly thought they were going to remove it, and then my county did the unthinkable, and to improve intubation success rate, made it mandatory for all cardiac arrest. We are suppose to intubate before trying a King tube or sticking to an OPA/NPA. I don't know if it has helped our success rate, but I remember hearing it was like in the 40%s. I was pretty happy that I was 85% and I just started bombing afterwards. I blame myself for things like not having my own equipment not ready or not communicating with fire before hand. I guess I was just lucky before hand.

 

[RocketMedic]

We run a 1st pass success ratio in the high 80s as a system by mandating "best pass" options like video laryngyscope and a supervisor on scene for all rsi. I reckon you need the right gear if you want to succeed in intubation, and to me, thats a good VL, a bougie, a King, capno and a plan