Alternative intubations. revisited

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bmc911

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was replying to a thread that discussed face to face or "Tomahawk" intubations and realized the last post was in 2008. well now i really want to sharemy experience and get some opinions and comments goin on this again, so figured ill start a new thread.:D


i have used the face to face method quite a few times and have had excellent results. where i find this to be beneficial is in tight areas. ill even use it when there is plenty of room and the patient is on the floor. havent tried it in a vehicle extrication yet but look forward to it. i also like the face to face from and educational stand point. you position someone at the head and give them a great veiw of the anatomy and the tube passing without interfering.

i have also used a similar method using two people when there has been difficulty intubating. one person approaches the patient as if they were about to face to face intubate but from the patients side and hold the laryngoscope and pull towards themselves or the patients feet. much better manipulation because it is a more natural and stronger arm movement. person passing the tube is in normal postion at the patients head and now has a free hand to apply selicks or BURP or change head position slightly or whatever that hand needs to do to better the view. i found this technique incredibly useful for obese patients with diffcult airway anatomy. the person with the scope does their part and the person passing the tube can use their free hand to lift the patients head farther into sniffing position for better alignment.

i have used both the face to face and this two person method many times with 100% success. ive done it with a medic student, an MD, and with another medic a bunch of times. i recomend trying both every chance possible, especially if your anticipating an easy intubation thats the best time to practice rather than trying to figure it out when its needed
 
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i've heard of this referred to as the "skyhook method." Interesting.
 
I've tried a face to face on an mvc once. The pt was entraped in a manner where his head was cranked forward and pinned in position by the roof. C-spine could not be moved into an inline position so there was no joy on the attemp. On the other hand I have long skinny fingers and have had success more than once on a digital intubation.
 
We've practice the Tomahawk style in class before, along with digital manipulation.

The digital one would scare the crap out of me.



Yet, as I'm a huge white cloud, I have yet to have to use an advanced airway. The only two times I would have was once in a hospital when they RSI'd a DKA pt but I was out of the room doing a 12-lead on someone, and the other was last week on a severe asthmatic... but CPAP worked till we got her to the hospital.
 
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I work in an archaic state that does not have field CPAP yet but I have come to the conclusion that it is best to just bag a CHFer. I have gotten signatures from more than one pt who was unresponsive and I was bagging when we rollled in the door.
 
A tomahawk intubation is a good skill to know and practice.. but in my experience, its something used in reality very rarely.. Ive been in EMS 12 years, and I think i've performed 2 of them... one of them just to look cool (in my early medic days)

I think a much better alternative to a tomahawk or a digital intubation is the SALT airway. Our agency is using them on a trial basis, and they work awesome in tight situations where access to the patient is limited WITHOUT having to cram your hands into someone's airway ( I have big hands.. NOT always easy)
AND they can be used on a BLS level as an OPA until ALS arrives...

with that said.. I'd prefer direct visualization of the larynx any day if I can get in a position to do it... and really I feel that's the gold standard.

I can see many medics becoming lazy with the SALT airway and using them on anyone and everyone they intubate, rather than a rescue airway, or a limited access airway.

There is always the option of placing a king tube, LMA, or combitube until you can get access to intubate, or just leaving the alternative airway in place if its working for you. You have to assess the situation and the patient and make the right decision.
 
FLEMTP said:
A tomahawk intubation is a good skill to know and practice.. but in my experience, its something used in reality very rarely.. Ive been in EMS 12 years, and I think i've performed 2 of them... one of them just to look cool (in my early medic days)

I think a much better alternative to a tomahawk or a digital intubation is the SALT airway. Our agency is using them on a trial basis, and they work awesome in tight situations where access to the patient is limited WITHOUT having to cram your hands into someone's airway ( I have big hands.. NOT always easy)
AND they can be used on a BLS level as an OPA until ALS arrives...

with that said.. I'd prefer direct visualization of the larynx any day if I can get in a position to do it... and really I feel that's the gold standard.

I can see many medics becoming lazy with the SALT airway and using them on anyone and everyone they intubate, rather than a rescue airway, or a limited access airway.

There is always the option of placing a king tube, LMA, or combitube until you can get access to intubate, or just leaving the alternative airway in place if its working for you. You have to assess the situation and the patient and make the right decision.
Click to expand...

I want to try the SALT in the worst way. Our county is actually in the process of removing all intubation from our protocols, God, SoCal sucks. Anyways, I have a history of getting patients with difficult airways, and while I can usually get them, the SALT seems like a great tool without the prohibitive cost of the Glidescope. Have you found that SALT does provide a patent tube most of, if not all of the time? I'm very interested in learning more about it.
 
Both are quite easy and very successful! Did a digital one a couple weeks ago.
 
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