Emergency Medicine Airway Management Discussion

Hello, everyone, and welcome to the August twenty

twenty-six Airway

of the Month. I'm Andrew Perrotte. I'll be your host.

I am an EM physician at the University of Kansas Health System and Medical Center,

joined by my colleague, Dr. Kyle Brown, also EM at KU, Dr.

Reba Hodge, EM Critical Care at Prisma in South

Carolina, and Dr.

Kristen Grabow, who is EM at Emory.

A couple points, we're sorting through some production side

of things, as we shared

in the last couple months. Uh, the captions are all a mess,

so I would encourage

you all when you watch this to just turn the captions off.

Uh, but we wanna keep this product going

and make sure we have consistency,

so we're gonna keep going as we sort out the background side of things.

So this month is

a interesting case, a lot of good teaching points.

So, uh, this is a GlideScope, probably a Mac

blade. I have a-- do have a conflict of interest.

I am on the Verathon Medical Advisory Board.

Keep that in mind always when you're listening to anyone with

conflict of interest.

Uh, but this looks like the black plastic of a

GlideScope blade.

Initially, a lot of secretions,

and the tongue is a little bit difficult to control.

So you see initially the blade is on the right side of the tongue, and

there's a fair amount of secretions.

Then the tongue flops down, and then provider goes

onto the left side of the tongue. I-- The blade are de-designed, and I would

always encourage to do the right to left sweep.

There is some commentary in the airway sphere about not

needing to sweep the tongue with VL, uh, but I disagree with that point.

I think you do need to still sweep the blade if you're using a Mac blade.

Now, if you're using an angulated blade, you do not need to sweep the blade, you

just scoop the blade.

So you'll see here epiglottis starting to become visible.

The

blade is seated in the vallecula. This is the tongue on the right

side. Lots of secretions.

Ducanto catheter comes in, does a great job.

We have no conflict of interest con-- with Ducanto, but he's just amazing,

and so

is his catheter. This is the point of the teaching, though.

So here's your view.

So this is epiglottis. This is tongue.

Reasonably good view, grade two B view probably.

Uh, the anterior commissure is not present and a little bit of, um,

reduction in view of the glottis may be a grade two A.

These are the arytenoids, the corniculate and cuneiform,

interarytenoid notch.

Can't really see the area of a glottic folds very well. This is piriform sinus.

Um,

but right now got a little bit of a lateral view of

the glottis, but more meaningfully is the cords are not paralyzed.

So if you look right here,

these are the vocal cords. This is what you are using paralysis,

so not only

to get the neuromuscular blockade and facilitate laryngoscopy and then--

but is also to facil-facilitate endotracheal tube passage.

And the cords here are spasming. They're still going,

so they're not paralyzed.

And so maintaining that view,

the

intubators here bring in their endotracheal tube, and this is actually,

I like what

I see. So they are hovering the endotracheal

tube, and you're starting to see the

cords paralyze. But instead of just ramrodding the

endotracheal tube

down when the cords are not paralyzed, they're just hovering

the endotracheal tube. You know what you got.

You're looking at the glottis.

You should be able to intubate, and instead of just getting nervous

and going for

it, you just hover the endotracheal tube right

above the glottis and watch the

cords paralyze.

So little bit of opening here.

The teaching point, though, is what happens to many of us

is what happens to this team. So, you know, you're going from cords

totally closed to cords partially open

and

just needs another few seconds, maybe fifteen, twenty seconds.

If the patient is receiving haptic oxygenation, has a good PO2

rever-reserve, is satting well,

everybody in the room is like, "Just get it done, just get it done."

And it's like,

well, if they're oxygenating well,

it's okay to just keep waiting. But it re-- is really hard.

It's easy to say, hard to do, but I would encourage you all

when you're in this

position, let the cords fully paralyze,

then introduce the endotracheal tube.

Here, they're getting there, but they're not quite there,

and you'll see the cords

are engaging the endotracheal tube.

Probably okay, as this tube looks like it passed fairly

atraumatically, but you can cause tracheal injury here,

which is very

real and has a ton of downstream effects.

So it's like when you're in this view right here, just give it another

fifteen or twenty seconds. And I would verbalize this to the room.

I would say, "Hey, we've got a great view.

We anticipate that we'll be able to intubate without any difficulty.

We have the tube right next to the vocal cords, glottis,

but the, uh, vocal cords are not paralyzed,

and we need more time for the

paralysis to take effect. And everybody calm down.

I know, you know, we've got control of the situation." Uh,

but it is very hard to

do, easy to say. So, but ultimately, successful airway

endotracheal tube does pass.

Little bit of resistance there, but ultimately, I think probably okay

and probably

still would not cause any harm, so. All right. That's it for this month.

Thank you all for listening and watching. We'll see you next month. Keep pushing.