Curved vs. Straight blades

[Carlos Danger]

What are paramedics being taught about the differences between the two basic laryngoscope blade designs?

 

[VentMonkey]

What are paramedics being taught about the differences between the two basic laryngoscope blade designs?

Provider preference, not much more that I am aware of, though I'd love a CRNA's insight.

Now, where can I find one?...

 

[TransportJockey]

Provider preference with Millers being easier for neos and pedis due to how they pin the epiglottis. And that Grandviews are so easy its like cheating

Sent from my SM-N920P using Tapatalk

 

[NomadicMedic]

I love the grandview. It's like intubating with a snow shovel.

I also learned it was provider preference.

However, in clinicals, a rather salty CRNA was telling me that he intubated almost everyone with a miller 2. He said, "the blade doesn't really matter after you've done 500 or so." He told me it was all about knowing the anatomy and your limitations. He also showed me a few different techniques that I thought were pretty neat.

 

[VentMonkey]

I feel like a Miller just doesn't give me the control I want for the majority of the adult population, particularly with large tongues.

I'm a Mac #4 guy myself. I feel it gives me the best shot at shoving everything off to the left allowing for a cleaner view, and it also provides the most maneuverability with most adults.

If it doesn't work the first time, I always keep a Mac #3 handy for my second attempt.

 

[TransportJockey]

I feel like a Miller just doesn't give me the control I want for the majority of the adult population, particularly with large tongues.

I'm a Mac #4 guy myself. I feel it gives me the best shot at shoving everything off to the left allowing for a cleaner view, and it also provides the most maneuverability with most adults.

If it doesn't work the first time, I always keep a Mac #3 handy for my second attempt.

My go-to is a King Vision w/ adults, with a Mac 4 as backup (the KV is roughly a 3.5 Mac-ish blade)

 

[VentMonkey]

My go-to is a King Vision w/ adults, with a Mac 4 as backup (the KV is roughly a 3.5 Mac-ish blade)

Our protocols dictate that we are to utilize DL first before moving to our King Vision.

Essentially, my approach would me DL/ Mac #4 and "Kiwi Grip" Bougie--->DL/ Mac #3 and "Kiwi Grip" Bougie---> King Vision.

 

[Nova1300]

This is a bit embarrassing to admit, but when I was slick at intubating I liked straight blades. However, now that I spent most of my time on the sidelines watching trainees intubate, I almost always reach for a Mac 3 when I have to step in. The few days per year I spend in the OR, I almost always ask the CRNA to let me intubate while they push drugs. And I go Mac 3. And I know they judge me for it

 

[VentMonkey]

This is a bit embarrassing to admit, but when I was slick at intubating I liked straight blades./QUOTE]
Nothing to be embarrassed of, IMO. It's been always taught as personal preference as long as I have known.

Out of curiosity, what was it that drew you to the Miller, and how did it help you in particular?

I have had a couple of successful ETI's with (one of which I rub in my then-trainees face til this day), I just could never find my niche with it.

Also, our old training coordinator swore by the Mac #3, and after he explained how it allowed him similar control as a 4, without the likelihood of obliterating the patients airway anatomy, I completely agree, and really have no excuses, reasoning, or proof other than preference and control I personally feel that a Mac #4 gives me in the "standard" adults airway anatomy.

 

[Carlos Danger]

I saw something somewhere on the interwebz recently where a paramedic said something about how certain blades are better for certain anatomy. I've heard similar things many times in the past, but I've never heard it explained. So I always wondered what the person saying it was talking about. Just wondered what you guys had learned about it.

In my CRNA training I don't remember ever even discussing it really. "You'll figure out what you like to use" was pretty much all we were taught about the blades. I do think it primarily comes down to personal preference.

When I was in the field I mostly used straight blades, because I was taught that most difficult airways are more amenable to straight blades. I continued using straight blades during CRNA school. One day a CRNA that I was working with said "Dude, curved blades are just easier to use. Why wouldn't you want to use what is easier?" Later in my training, an anesthesiologist who I liked a lot told me that "a miller 2 is the only blade worth knowing", his rationale being that while in most patients it doesnt matter at all which you use, there are some that a straight blade works better in, so it makes sense to use that blade type routinely so you are really comfortable with it in the case that you need it.

Since I finished my training about 1.5 years ago, I've been using curved blades pretty much exclusively. I'll reach for a straight blade now and then just because. I really think curved blades are easier to use in general - they just take a little less work to get a good view with. I like a mac 3.5 if I can get one (we don't have them where I work now, unfortunately), or a mac 4. The only time I think straight blades are really better (as in easier to use) are in patients with a really small mouth opening - there's just less metal to try to fit between the teeth.

 

[VentMonkey]

Ya know? It's threads like this that really make me glad I joined this forum.

 

[Nova1300]

It's funny, I never really sat down to contemplate why I grew to like the straight blade in my early years. I liken it to smoking, everyone was doing it and it looked cool.

I was taught a peritonsillar placement for straight blades and a hefty sweep up and left. And with a good deal of practice, I eventually was able to get better views on most patients with this technique than I could obtain with a Mac. But like many things in life, if you don't use it, you lose it.


I wouldn't touch an edematous, gastric tube-filled, slimy ICU patient larynx with a straight blade now. The art of intubation is lost on me in this population. It's more of a "shove as much as you can out of the way with the blade and suck out the remaining crust with the rigid suction catheter until you see something that resembles a vocal cord" approach.

I probably look like an orthopod trying to intubate in these situations. Shame.

 

[Handsome Robb]

I was taught that straight blades you place the tip on the epiglottis and pin it out of the way whereas a curve you place the tip into the vallecula and lift which pulls the epiglottis out of the way.

I used to cheat and use a grandview as my first choice but once we went to disposable blades I'd use a Miller 2-3 depending on how I was feeling.

Now I'm required to use the King Vision on all intubations so it's a moot point.


Sent from my iPhone using Tapatalk

 

[DesertMedic66]

I was taught that straight blades you place the tip on the epiglottis and pin it out of the way whereas a curve you place the tip into the vallecula and lift which pulls the epiglottis out of the way.

I was taught that also. For us during medic school we were forced to use both straight and curved to find out what we preferred.

We were also taught that usually straight is easier for infants however sometimes curved will work better.

 

[Handsome Robb]

We were also taught that usually straight is easier for infants however sometimes curved will work better.

I was taught the same thing. I've actually intubated more kids than adults. Ok it's probably about even now actually and I never had an issue using Miller blades for them. Never tried a mac blade though.


Sent from my iPhone using Tapatalk

 

[NomadicMedic]

There's no VL at my current service, so I'm a kiwi grip bougie and mac 4 guy usually. (Every tube is on a dead person during CPR, so I make it easy on myself)

 

[akflightmedic]

I prefer my digits...ain't nothing like hooking in their mouth the way you noodle for a catfish. Hit the sweet spot and drop the tube...why mess with any blade when you can noodle?

 

[VentMonkey]

I prefer my digits...ain't nothing like hooking in their mouth the way you noodle for a catfish. Hit the sweet spot and drop the tube...why mess with any blade when you can noodle?

Our medical director is huge on bimanual ELM (detests cric pressure; another "hot button" airway topic), and had emphasized how it frees your hands to do such things as manipulate the airway to your liking.

I have also seen/ heard of utilizing a second provider to "fish hook" the cheek for even further maneuverability/ wiggle room.

 

[NomadicMedic]

In a difficult airway class I medic school I learned the tomahawk method, where a second provider stands over the patient and pulls straight up on the handle. Shortly afterward, I used it on a 500 pound Samoan guy and it worked like a champ. My preceptor about **** himself.

They were busting my balls, "hey medic student, can you get this tube?" Damn right I'll get that tube.

Now, of course, I'd be all like, "just put a king in..."

 

[VentMonkey]

In a difficult airway class I medic school I learned the tomahawk method, where a second provider stands over the patient and pulls straight up on the handle. Shortly afterward, I used it on a 500 pound Samoan guy and it worked like a champ. My preceptor about **** himself.

They were busting my balls, "hey medic student, can you get this tube?" Damn right I'll get that tube.

Now, of course, I'd be all like, "just put a king in..."

When you say difficult airway class, are you referring to thee "Difficult Airway Course" designed to coincide with the Ron Walls book?

I was thinking about taking the one in LV later this year, but scheduling changes prevented me from following through. I'm wondering if anyone has taken it, and if so what they thought.