Head Positioning for Intubation During CPR

Tigger

Tigger

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Had an arrest today secondary to a hanging and a large amount of alcohol. Anatomically this patient did not appear to present as a difficult airway, but given the first two things, we planned for difficultly.

I struggle with finding ways to stabilize the patient's head while they are undergoing compressions (obviously pausing for airway management is a no). What's your go to? I wanted very much to ensure ear to sternal notch alignment in this patient, but I think made this intubation harder on my self by inadvertently flexing the patient's neck by placing a rolled towel under the occiput. The head was at the right height, but the positioning was still not ideal.

Also used the Ducantol suction cath today. Worked great to clear mass amounts of blood and vomit, but I could not get it stay planted in the esophagus with compressions. Also intubating with a large suction cath in the mouth did not make things easier. Had to abandon the McGrath after it became grossly contaminated, which my whole goal was to avoid the Ducanto.
 
It sucks but Sometimes you just can't get the best position you would like. I like to try to ramp them with blankets under shoulders and neck if needed tho is harder to do while CPR is in progress.

With the decanto suction device I've had good luck with it And like it. I'm assuming you have watch the videos on its use? I know it feel awkward but with the esophagus diversion technique it seems to make more room when you get the suction Cath moved over to the left side of your scope then you still have the right side for your intubation.
 
Up your SALAD game bro!

Positioning wise, I have the luxury of having Lucas in my system, so we can pad under the shoulders and in some cases ‘ramp’ the patient on the gurney with ongoing CPR.

In terms of difficult airway management, Dr. DuCanto has a bunch of great techniques that our system uses (he has a been featured on EMCRIT and his ideas have subsequently been taught and shared all over the Internet. Try these ideas next time:

- Suction before before inserting your VL of choice, then continue to suction as you advance your blade, never passing the tip of the blade past the suction catheter. If the camera gets does get soiled, grab a flush and squirt it on the camera without removing the blade from a the Pt’s mouth.

- Tube the esophagus (yes, you read that right) with an 8.0 tube and attach suction to it, then intubate the trachea.

- Using your suction catheter (preferably a DuCanto) to clear the area around the glottic opening. Then park the suction catheter in the glottis, unplug the suction tubing, pass a bougie down the suction cath, remove the suction cath, and pass a tube over the bougie.
 
I take a stack of our blankets off of the stretcher. They are wide enough the head won't fall off, pliable enough to position how I want, but solid enough to keep the head in position. And that auto pulse rocks the **** out of a head, but this works very well. I don't roll the towels though, just stack them like you would in the truck. I have not had a patient I could not intubate in an adequate time this year after making changes like this.

If there is that much coming from the espohagus, I'd probably put an 8.0 in the esophagus it first as well.

I actually listened to an emcrit podcast not too long ago on this very subject. Check it out, it provides some solid info on how to approach these airways that I have already used recently.

https://emcrit.org/pulmcrit/drowned-airway-algorithm/
 
I also ramp these patients with a bunch of progressive padding.

DuCanto suction caths are life. Spend as much time as you need to suction the airway and if you need to, you can visualize the glottic opening, stuff the DuCanto in it, pass a bougie through and then intubate over it. It's a neat trick.
 
NomadicMedic said:
I also ramp these patients with a bunch of progressive padding.

DuCanto suction caths are life. Spend as much time as you need to suction the airway and if you need to, you can visualize the glottic opening, stuff the DuCanto in it, pass a bougie through and then intubate over it. It's a neat trick.
Click to expand...
This is what I ended up doing. Had to grab the DL as the camera got quite contaminated but the amount of suctioning needed was insane. Try as I might I could not get that ducanto to stay in the mouth. Fortunately I got a decent enough view to get the bougie in.
 
Tigger said:
This is what I ended up doing. Had to grab the DL as the camera got quite contaminated but the amount of suctioning needed was insane. Try as I might I could not get that ducanto to stay in the mouth. Fortunately I got a decent enough view to get the bougie in.
Click to expand...
Second set of hands standing off to the left?
 
SALAD technique is a little difficult at first and takes practice. It can be lot of stuff in the mouth and a lot of manipulation and takes time to figure out out what works for you. I have had a hard time directly passing an ETT with the DuCanto and always use a bougie and remove suction to pass the tube if I have tube.

Really get the DuCanto deep into the esophagus if you can. Sometimes I feel it would work better for this backwards, if you don't get it passed the curve it wants to pop back out. Doesn't really help if the bleeding is proximal tho (GSW) and you just have to get a view and go.

You can also try placing an NG tube before your attempt.
 
Tigger said:
Had an arrest today secondary to a hanging and a large amount of alcohol. Anatomically this patient did not appear to present as a difficult airway, but given the first two things, we planned for difficultly.

I struggle with finding ways to stabilize the patient's head while they are undergoing compressions (obviously pausing for airway management is a no). What's your go to? I wanted very much to ensure ear to sternal notch alignment in this patient, but I think made this intubation harder on my self by inadvertently flexing the patient's neck by placing a rolled towel under the occiput. The head was at the right height, but the positioning was still not ideal.

Also used the Ducantol suction cath today. Worked great to clear mass amounts of blood and vomit, but I could not get it stay planted in the esophagus with compressions. Also intubating with a large suction cath in the mouth did not make things easier. Had to abandon the McGrath after it became grossly contaminated, which my whole goal was to avoid the Ducanto.
Click to expand...

I would’ve done the same thing with the rolled towel/blanket under occiput or shoulders, it just seems to be the most sensible thing. But again, field RSI is not a common occurrence where I’m at, and in the ER the doc/RT are using the GlideScope and the bed isn’t exactly bobbing left and right.
 
My last hanging patient we also had difficulty on visualization. Even with aggressive suctioning, damage to the structures made me and my partner less than confident on placement of a ET using DL. We went with the Igel. Ive been criticized as "giving up" for not trying to intubate, but with the way this guy was presenting, likelihood of a positive outcome was low and screwing around on scene wasnt ideal.

That said, with the deployment of Lucas to all our ALS units, i have done 3 intubations standing over the patient with them sitting up in a low fowlers or high ramped position. It has allowed us far greater freedom in getting good airway positioning than with manual CPR
 
Bullets said:
We went with the Igel. Ive been criticized as "giving up" for not trying to intubate...
Click to expand...

By morons, I assure you...I've had intensivist attendings throw in an sga with the anticipation we'd intubate in the OR under controlled, advanced setting...discretion is the better part of valor is something the big dawgs know very well, but the yappy chihuahua's are kind of lost on...
 
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