Intubation tips?

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ParamedicStudent

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Hello, I'm doing my field internship right now, and I'm horrible with intubations. I've had about five intubation attempts and two king airways, and I failed all of my intubations. My first three attempts where in a moving rig, and my next two were were during cpr. It's definitely more difficult than doing it on a mannequin. Are there any tips you guys can throw out there? How much pressure do you have to apply while lifting up the tongue? There were some cases on which I was able to visualize the vocal cords, but can never get my tube in.
 
1. Don't rush. That's easier said than done when a patient is sick and your adrenaline is flowing, but it is important. Learn to control your anxiety. Control your breathing, keep your thoughts focused and in order. Use a checklist.

2. Positioning. It can be challenging in an ambulance or on a living room floor, but optimizing positioning is probably the single most important thing you can do. You need to bring mouth opening, pharynx, and glottis as close to alignment as possible. Picture what position the head would have to be in, in order to be able to draw a perfectly straight line though the mouth and into the glottis. The head of the stretcher should be elevated some and the head supported and extended such that the earlobe should ideally be above the level of the sternum.

3. Laryngoscopy should be slow (yes, slow) and methodical. Use a curved blade and slowly advance it under the tongue into the vallecula. Straight blades have an advantage in certain airways but I really think curved ones are easier to learn on, and work well the vast majority of the time.

4. If you are having trouble getting a view, place your right hand under the occiput and lift until you've aligned the axes that I mentioned in number 2. Or, if the head is already in good position, use your right hand to manipulate the larynx to bring the glottis into view.

5. I never use a stylet in my tubes. A tube will usually maintain it's neutral curved shape just fine without one, and not having the stylet in it will allow you to change the curve of it a little just by placing pressure on it certain ways with your fingers, not unlike the way you manipulate a bougie (hard to describe, but grab one and play with it and you'll see what I mean). In the occasional case where I find that I do need the tube to have some rigid support in order to direct it into the glottis, I simply reach for a bougie.
 
1. Stop the ambulance. The key to successful intubation is optimizing the environment. There are somethings you can't control such as secretions/blood/Mallampati so take control of the things that you can control. It's a lot easier to place the tube in a stationary position than it is with the pt bouncing around. Anyone that tells you that you should be able to do it while moving is just trying to be a cowboy.

2. Make sure you have the pt positioned properly.

When you could see the cords, what was preventing you from being able to pass the tube?
 
1. Always suction first
2. Down size blade and et tube. Generally mac 3/ miller 2 is great for most adults gives you more room in the mouth to work. One study suggest success rates reduce 50% for every ET half size above 7.5.
3. Bougie helps
4. RAMP/HELP position
5. Ear-to-sternal notch
6. Listen to podcasts. Rich levitan. EMDOCS. "Tips for the occasional intubator" by lifestar podcast. Etc.
7. Understand anatomy. Epiglotoscopy. The uvula points towards the vocal cords, so look for the uvula first.
8. Go slow dont rush. Do it right the first time.
 
Make sure you are thoroughly preparing everything before intubating. Pt, position, oxygenation, back up, suction, and anything else you thing you will need before doing anything.

1. Ensure good preoxygenation and that they have a decent pressure before starting.

2. Position your airway. Grab some towels or blankets and get the head set right. I haven't personally done this yet, but elevating the head of the stretcher has been shown to increase first pass success as well. Preparation here makes a big difference.

3. Use a bougie. If you bump it wrong, it won't become misshapen like a stylet and I don't have the experience to mess around with an empty tube comfortably (done it, but it's a different feel). I find a bougie to be easier to control and direct.

4. Take time to find your landmarks, know what you are looking for and at.

5. Stop the damn truck. 30 seconds won't matter for many, especially if that means everything is done right the first time in a timely manner.
 
1. Get those sats above 95 if you can. That buys a lot of time, once the sats drop below 90 theyll keep dropping fast.

2. Stop the truck, dont stop CPR

3. Use a bougie

4. Sweep the tongue to the left. Youll be surprised how much clearer the view is as opposed to just lifting it.

Sent from my SAMSUNG-SM-G920A using Tapatalk
 
All good tips, and everyone has and is displaying excellent pointers.

We just did an airway update class with our medical director and his stance was that stylets still have their place as they can help you manipulate the ETT with, say, an anterior airway.

Anyhow, you can't go wrong with my personal favorite, and what I like to call the "airway bible", Dr. Walls' book. It's also spawned a website, courses, and podcasts (webinars):

https://shop.lww.com/Manual-of-Emer...e=link+connector&medium=aff&utm-content=46514
 
The Walls book is excellent. It is one book that I think every clinician who does airway management should read.

There are only a few texts that I try to keep current copies of, and this is one of them.

If you want an airway text that goes a little more in depth and advanced, Benumoff's is pretty much the airway bible for anesthesia.
 
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@Remi have you taken any of their courses, and if so would you recommend it?
 
@Remi, do you have any online resources that you have found insightful? Airway manipulation is one area I probably haven't looked up much on in terms of videos, but for the time being those are my best resources to use.
 
I don't think there is anything I could say that hasn't already been said as far as practical advice goes. Listen to these guys especially @Remi. Here are a couple of sayings regarding intubation that I love and would like to share.
"Experience is Delusory"
"A failed airway is not a failure, it's a diagnosis not an accusation"
The bottom line is that being in charge of managing an airway means all aspects of it, not just knowing how to intubate.
 
Ooh i like that last one. I take pride in being a good airway manager and not just a good intubator.
 
Here's the guts my mate ... airway doesn't mean intubation, it means using whatever works; if that's just a good old jaw thrust and scoot down the road to hospital then that's it, or getting some bystanders to sit on somebody whos a bit fighty cos of their hypoxic brain injury until an RSI Officer arrives then that's what it is.

Intubation is useful, but outside of RSI it probably doesn't have much of a role to be honest; unless the patient is so unconscious they can easily be intubated without general anaesthesia and muscle relaxation.

Now, with that in mind ... make sure you have all your gear set up and ready including backup equipment, and take the time to the get pt into a good position, and use an intubating bougie; can't fail if you use of those cos you can very clearly hear when it's in the trachea. Oh, and make sure you're using exhaled numeric CO2, if you;re not then your service needs to get it like fast like yesterday fast.
 
Has anyone ever used the BURP technique? What was your experience?

Also, how do people feel about using a Mac blade but overshooting past and lifting the glottis with it? I've unintentionally done this on the airway mannequin and it also happened on a cadaver with a really anterior airway. Visualization is visualization? Or are we concerned about trauma to the glottis (though keeping in mind a Miller is intended to be used this way)?
 
I imagine most of us on here have at some point heard of or been taught Back, Up, Right pressure aka Sellick Maneuver aka Cric pressure. I also imagine that most also agree it is outdated and have substituted for ELM (External Laryngeal Manipulation) as a part of Bi manual Laryngoscopy. But this does remind me of an amazing talk by an amazing man.. RIP John Hinds "Don't be a Resus Wanker"
 
CWATT said:
Has anyone ever used the BURP technique? What was your experience?

Also, how do people feel about using a Mac blade but overshooting past and lifting the glottis with it? I've unintentionally done this on the airway mannequin and it also happened on a cadaver with a really anterior airway. Visualization is visualization? Or are we concerned about trauma to the glottis (though keeping in mind a Miller is intended to be used this way)?
Click to expand...

im not against this if it happens, but would not recommend it becoming a habbit. The tip of the mac blade can deflect the ET tube when you attempt to insert it.
 
FLMedic311 said:
I imagine most of us on here have at some point heard of or been taught Back, Up, Right pressure aka Sellick Maneuver aka Cric pressure. I also imagine that most also agree it is outdated and have substituted for ELM (External Laryngeal Manipulation) as a part of Bi manual Laryngoscopy. But this does remind me of an amazing talk by an amazing man.. RIP John Hinds "Don't be a Resus Wanker"
Click to expand...

I feel the need to clarify -for those unfamiliar- that the Sellick Maneuver and BURP technique are two different interventions. Sellick Maneuver is intended to obstruct the esophagus to prevent gastric insuflation during bag-valve-mask ventilation. It is intended to be sustained during management of the airway. The BURP technique (Backward, Upward, Rightward Pressure) is intended to assist visualization of the glottis during intubation by realigning the airway to counteract manipulation created during lyringoscopy and is not intended to be sustained.

That said, Cricolol. (LOL!). Brilliant. That video is exactly why I asked.
 
@CWATT, just to clarify, my intention was not to say they are the same thing as much as saying that they are both outdated.. Thus my mention of ELM and Bi manual laryngoscopy.. I should have been more clear and understand and apologize for any confusion I may have caused.
 
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