1. Video Laryngoscopy in Cardiac Arrest
Colby J. Rowe MS, NRP, FP-C
Stony Brook Medicine
Stony Brook, New York

2. Introductions Colby Rowe, MS, NRP, FP-C
Clinical Instructor of Emergency Medicine
Clinical Simulation Coordinator, SOM
BLS, ACLS, PALS TC Faculty
The Difficult Airway Course: EMS™
Northeast Regional Director
Italy, South Korea, Canada

3. Presenter Disclosure Information
Video Laryngoscopy in Cardiac Arrest
Colby Rowe
FINANCIAL DISCLOSURE:
none
UNLABELED/UNAPPROVED USES DISCLOSURE:

4. Objectives
Discuss the evolution of advanced airway management techniques.
Discuss how the 2015 AHA Guidelines for CPR & ECC apply to advanced airway management.
Understand importance of First Pass Success in advanced airway management.
Learn techniques of video laryngoscopy to achieve First Pass Success!

5. Today Two Days Ago in History
December 7, 1963
Army-Navy football game
 It was early in the fourth quarter of the 64th Army-Navy football game. Army quarterback Rollie Stichweh broke a tackle from 1 yard out and ran in for a touchdown. A few seconds later, television viewers watched it again -- the first instant replay.      "This is not live!" CBS announcer Lindsey Nelson said. "Ladies and gentleman, Army did not score again!"

6. Airway, Beating…and Circulation?

7. History of Cardiac Arrest Airway Management
Egyptians & Romans
Tracheotomies?
William Macewaen (Scotland, 1880)
ETI for obstruction
Joseph O’Dwyer (USA)
Blind passage
In 1880, in Scotland, William Macewen described how to relieve airway obstruction by passing an oral tube into the trachea. He practiced blind, digital intubation using cadaver models and eventually was able to use this technique clinically.
One important problem with the O’Dwyer intubation system and its variants was that they had to be placed blindly. The next important development in clinical airway management was thus the development of direct laryngoscopy, which allowed visualization of the glottic structures.

8. History of Cardiac Arrest Airway Management
Benjamin Guy Babbington
Glottiscope
Philipp von Bozinni &
Garignard de la Tour
“Mouth Mirrors”
Manual Garcia (1854)
Vocal teacher used sunlight and mirrors
First direct visualization of human glottic opening

9. History of Cardiac Arrest Airway Management
Chevalier Jackson (1913)
“Father of endoscopy”
Introduced light source on distal end of blade
Henry H. Janeway (1913)
Anesthesiologist
Introduced battery operated laryngoscope
Sir Robert Reynolds Macintosh (1943)

10. Direct Laryngoscopy Conventional laryngoscope
Technique utilized to facilitate direct visualization of the glottic opening when performing endotracheal intubation.

11. History of Cardiac Arrest Airway Management
Pioneers
Dr. Peter Safar
Dr. James Elam
Manual maneuvers
Mouth-to-mouth
A, B, C’s of Resuscitation
The Breath of Life

13. The Late Dr. John Hinds Modern day resuscitation guidelines.
ABC’s as Safar wrote.
“Gold Standards”
Poor outcomes in OHCA (out of hospital cardiac arrest).
Challenges

14. Challenges Delivery of Oxygen (DO2) in Cardiac Arrest
Methods of ventilation
Basic v. Advanced strategies
Manual maneuvers
Devices and adjuncts
Early v. Delayed ETI
Control
Protection
Carbon dioxide
Less invasive techniques
Experienced clinician

15. Challenges Endotracheal Intubation Success rates of 75-90%
TTI (time-to-intubation)
Interruptions in CPR
Difficult intubations
Unrecognized esophageal or dislodged ETT
Adjuncts
Fraction of oxygen
Ventilation rates & strategies

16. 2015 Guidelines for CPR & ECC
BVM or ETI?
SGD or ETI?
What does the science say?
“Low quality evidence”
“The type of airway used may depend on the skills and training of the healthcare provider.”

17. So…Why Are We Here?

18. John C. Sakles, M.D.
University Arizona Medical Center Emergency Department
61 beds
70,000 ED visits
July 2007-June 2013
Approximately 3000 intubations
Half DL & half VL
100% capture

19. The Data

20. The Data

21. The Sakles Conversation

22. First Pass Success
Sakles et al., International Journal of Emergency Medicine (2013)

23. First Pass Success

24. The Sakles Conversation

25. Evidence Assessed GVL, Pentax AWS, and DL
15-30° lateral left tilt with LUCAS
TTI and success rate
TTV and TTI

26. Evidence

27. Evidence Assessed GVL in simulated CPR
GVL v. DL with and without compressions
“Extremely high success rates”

28. Evidence EMJ-Tandon et al (October 2014) 20 EM physicians
DL, GVL, and GVL-Bougie
TTI with compressions
Results
DL (27s)
GVL (20s)
GVL-B (60.1)

29. Evidence Journal of Emergency Medicine-Sakles et al (December 2014)
460 unsuccessful first attempt adult OTI’s ( )
CMAC v. DL for rescue attempt
after failed
Results
CMAC: 116/141 (82.3%)
DL: 58/94 (61.7%)

30. Evidence Resuscitation- Park et al (December 2014)
305 OHCA (May 2011-April 2013)
Compared first pass success
83 intubated by novice emergency physicians in the field
Results
VL (n=49) 91.8% successful
0 interruptions in compressions
0 esophageal intubations
DL (n=34) 55.9% successful
Median of CCI was 7 seconds
1 esophageal intubation

31. Video (Indirect) Laryngoscopy
Use of a micro-video camera along a laryngoscope blade transmitting image to an external monitor.
Facilitates indirect visualization of the glottic opening when performing endotracheal intubation.

32. Tips for Success Keep it similar! Look for blade! Go midline.
Keep your distance.
Compress tongue directly into submandibular space.
Go 3:00-12:00 (back in time that is).
Alternate practice.

33. The Devices Outline Video Laryngoscopy Optical Laryngoscopy Glidescope
C-MAC
McGrath
King Vision
Optical Laryngoscopy
AirTraq
Technique different than with DL
Requires training and practice
Visualization vs. tube delivery
Cost can be much greater than with DL
Cost coming down
May be inferior when lots of secretions

34. Optical Laryngoscopy Placed midline Lift in the vertical plane
Align vocal cords center
Slowly advance ETT through cords
Disengage ETT and remove device

35. Wrap-Up We need to minimize hands off time
VL can minimize interruptions in chest compressions and increases compression fraction
VL improves First Pass Success!
“Practice doesn’t make perfect; perfect practice makes perfect”

36. Thank You!