#6 Essential Emergency Airway Care-Video Laryngoscopy Andrew Brainard, MD, MPH, FACEM, FACEM http://www.thesharpend.org/ abrainard01@gmail.com

#6 RSI and Video Laryngoscopy Learning Objectives Prep team/plan/room/equipment Mask seal, BVM, adjuncts, suction Pre and apnoeic oxygenation Pt Positioning Airway assessment and plan MOANS/LEMON Announce “pullout criteria” Briefing for Plan A, B, C, & D Completes FINAL airway checklist Call and response <1 min Manual InLine Stabilization Video laryngoscopy Indications/Contraindications Advantages/disadvantages Proper Technique Confirm and secure tube Solving difficult tube passage problems Use suction early Back off camera Use prebent stylet Pre-curve bougie External Laryngeal Manipulation Advance ETT off stylet Complete Airway Audit Form R40: 25y/o M rollover RTC GCS 10, SaO2 98%, P 140, BP 140/70. Agitated with head injury In C-collar On arrival LEMON shows: No facial trauma, No blood in airway, normal 3-3-2, gurgling Predicted difficult airway: in C-collar Consultant suggests Glidescope Patient can only be intubated using Manual Inline Stabilization Suction Video laryngoscope Best Look Techniques External Laryngeal Manipulation End scenario after tube confirmation Discuss solving difficult tube passage

Types of indirect laryngoscopes

Indications for Video Laryngoscopy? Absolute Contraindication: Inability to oxygenate patient Cricothyrotomy Indicated for: Primary Secondary Relative Indications: Predicted difficult airway? Spinal precautions? Relative Contraindications: Fluid in the airway (like blood or vomitus) that cannot be cleared with suction Operator inexperience Reserving VL as only a rescue device is dangerous Practice before you need it as a rescue device Mihn, Learning from failed intubations- a study of 3 videos:: http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ (Accessed on 1/6/2013)

Video Laryngoscopy Direct Laryngoscopy

Pre-Oxygenate >3min (Attempt to get oxygen to 100% for several minutes before RSI) Non-Hypoxic or Hypoxic/Hypoventilating Patient Nasal Cannula Oxygen as high as tolerated BVM Mask Seal/PEEP/ETCO2 Non-Hypoxic patient Nasal Cannula Oxygen as high as tolerated Rebreather Mask

Nasal Apneic Oxygenation Apneic Period Nasal cannula O2% to >15 lpm Jaw thrust / NPA / laryngoscope

Positioning Ear-to-sternal notch level Face parallel to ceiling RAMP Head up Bed height

Formal Airway Assessment LEMON L- Look E- Evaluate the 3-3-2 rule 3 pt fingers in the mouth 3 pt fingers under the jaw 2 pt fingers from thyroid to jaw M- Mallampati / Mouth O- Obstruction N- Neck Mobility Fluids can make video laryngoscopy more difficult

Teeth Anterior Tongue Tonsils Posterior Tongue Uvula Soft Palate Hard Palate

4 step Glidescope Look directly at patient’s mouth Insert midline Use suction early Watch mouth until tip passes out of view Look at the screen after tip passes into posterior oropharynx. Use screen to visualize epiglottis. Insert tip of into vallecula Apply upward pressure Visualize the vocal cords and glottis Suction if needed. Look at the mouth Pass the stylet’ed ETT (or a prebent bougie) into the mouth Look again at the screen Advance ETT off stylet into the glottis Mihn, Learning from failed intubations- a study of 3 videos:: http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ (Accessed on 1/6/2013) Using the Glidescope http://www.youtube.com/watch?v=7jb2tbqQ6VQ (3min)

Epiglottis-Laryngoscopy-Tube Passage #1- Prepare Prepare Team- (EEACC #1) Optimize pt Oxygenate pt- (EEACC #2) Position optimally - (EEACC #2) Prepare Glidescope Warm up Select blade size ~4 for tall men ~3 for most patients #2- Visualize Epiglottis Mouth then Screen #3- Visualize Glottis Place blade above vallecula Visualize the arytenoid cartilage #4- Pass Tube Watch mouth and insert tube Watch screen Re-maximize your view Advance tube through glottic opening Advance tube off stylet through the glottic opening Four secrets to video laryngoscopy- Richard Levitan Emergency Physicians Monthly by December 12th 2012: http://www.epmonthly.com/features/current-features/four-secrets-to-video-laryngoscopy-/ (13/06/2013/03) More Glidescope http://www.youtube.com/watch?v=BvpUI7vOpDw (6min)

Difficulties with Glidescope? Lubricate exterior of blade, ETT and stylet Remember geometry Use stylet Prebend bougie Don’t “Over Zoom” Keep camera far away from glottis Backing up camera Keep epiglottis in view Place the blade above vallecula Glottis in the centre top third of screen Manipulate patient Elevate head, lift jaw, use ELM Advance ETT off end of tube Withdraw the stylet Advance tube off end of stylet through the cords (like an IV cath) Don’t task-fixate on the picture Watch the sats Prepare plan B, C, D… Difficult Video Laryngoscopy:  http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ (30min) Common errors with glidescope: http://www.youtube.com/watch?v=0Z0s8875yc4 Mihn, Learning from failed intubations- a study of 3 videos:: http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ (Accessed on 1/6/2013) Common errors with glidescope: http://www.youtube.com/watch?v=0Z0s8875yc4 Difficult Video Laryngoscopy:  http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ (30min)

Airway briefing and checklist We have a 50y/o female victim of head trauma who needs to be intubated because she is not protecting her airway. Based on our formal airway assessment, it is appropriate to proceed. We will RSI with 100mg of Ketamine and 100mg of Rocuronium. The team will be: I’ll be team leader JoAnn as primary airway operator Fred will hold manual-inline c-spine stabilization I’ll be the backup airway operator Chris as airway assistant Henry also push the drugs Our plan is: A- Video/7.5 tube w/stylet B- Direct/bougie/7.5 tube C- AirQsize #3.5 D- Cric for Sats <80% and dropping We will pullout if SaO2 drops below 93% or if we can’t see anything after 1 minute. We will re-oxygenate after each attempt. Everyone understand their roles? Questions or suggestions? Is everyone ready to complete the checklist in less than a minute? Andy JoAnn Andy Chris Chris- Bimanual Fred Andy 14

Brief Video Laryngoscopy References: Glidescope, 4-step technique: https://vimeo.com/38937634 Levitan, Four Secrets to video laryngoscopy: http://www.epmonthly.com/features/current-features/four-secrets-to-video-laryngoscopy-/ Mihn, Learning from failed intubations- a study of 3 videos: http://prehospitalmed.com/2013/05/14/learning-from-failed-intubations-a-study-of-3-videos/ John Doyle Eight Intubations using the Color GlideScope Video Laryngoscope http://www.youtube.com/watch?v=BvpUI7vOpDw (Accessed on 24/4/2013) Levitan RM, Heitz JW, Sweeney M, Cooper RM. Ann Emerg Med. 2011 Mar;57(3):240-7. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices.