A School of Airway:
Airway One
Airway One
56-45 Main Street
Flushing, NY 11355
United States
ph: 347 724 4244
alt: Attention: Jose D. Torres, Jr., MD
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You must remember the following. Such Details will maximize your Airway Skills with the COLD STEEL.
PREOXYGENATION: Prevent desaturation during attempts at intubation by maximized pre-oxygenation. Read this article.
POSITIONING: Names are being used for the best patient positioning for ventilation/intubation. Ear to Sternal Notch, or Sniffing position. I call my version the Mike Shin Manuever named after one of my em residents who looked at this picture and realized its harder to use the many chucks and pillows and towels, than using the ed stretcher the patient is in.
SENIOR CARE Manuever: when your stretcher or bed patient is in, doesn't have a head section that can be raised, or not enough time to find and set up the sheets for head positioning, sometimes you can use the strength of another to improve your visualization of the airway.
BLADE SWEEP: Coordinate your wrist/hand sweep with Blade Insertion, and Tongue sweep.
- PREOXYGENATION
THIS HAS CHANGED A LOT WITH THE ADVENT OF USING THE NASAL CANNULA ALONG WITH THE FACE MASK FOR PREVENTING DESATURATION DURING INTUBATION ATTEMPTS. ONCE THOUGHT FRIVOLOUS, NOW PROVING VERY ESSENTIAL FOR PROVIDING A RESERVOIR OF HIGH CONCENTRATION OF OXYGEN. THE FACE MASK STILL ATTEMPTS TO WASH OUT THE PATIENT NITROGEN IN THE PATIENT'S LUNGS. CLICK HERE TO READ THE ARTICLE.
- SHAPING THE ETT
NO BOOMERANGS FOR HUNTING PREY IN THE OUTBACK OF AUSTRALIA. YOU ARE RESPONSIBLE FOR RESHAPING THE TUBE WHEN HANDED TO USE, AND TO LOADING IT UP WITH A STYLET. STRAIGHT TO CUFF SHAPING AS SUGGESTED BY LEVITAN ALLOWS FOR NEGOTIONING FOR THE LEAST AMOUNT OF ORAL CAVITY SPACE FOR SUCCESSFUL INTUBATION.
- STANCE OF COMFORT
NOT A FIGHTING STANCE, BUT STANCE OF COMFORT FOR INTUBATION. NOT A POSITIONING OF INSTABILITY THAT WILL LEAD TO APPEARANCE OF DEFECATION/EXTERNAL HEMORRHOIDS.
- MIKE SHIN MANUVER
THIS MANUEVER WOULD NOT BEEN POSSIBLE WITHOUT THESE 2 PICS OBTAINED FROM AIRWAYCAM.COM, AFTER TEACHING MY RESIDENT ABOUT APPROPRIATE POSITIONING OF THE PATIENT NEEDS TO BE DONE BEFORE RSI IS GIVEN, OR ANY INTUBATION ATTEMPT DONE. ALSO BECAUSE IT'S TOO MUCH WORK TO USE ALL THE TOWELS OR CHUCKS/PILLOWS IN THE ED FOR POSITIONING ONE PATIENT.
- SENIOR CARE EMS MANUEVER
SOMETIMES THERE IS NO LUXURY OF USING A BED WITH AN ADJUSTABLE HEAD REST TO GET THE MICHAEL SHIN MANUEVER DONE. SOMETIMES THE EAR TO STERNAL NOTCH ALIGNMENT IS OBTAINED FROM BILATERAL ARM PULLS FROM ANOTHER PARTNER.
- HOLDING THE BLADE, THE COLD STEEL
ALLOW FOR MAXIMUM CONTROL OF THE BLADE. HOLD IT AS LOW AS POSSIBLE.
- BLADE SWEEP
OFTEN UNDER ESTIMATED NUANCE IN HANDLING A BLADE. MANY TIMES DONE AS AN ADJUSTMENT TO A PATIENT WITH BOUNTIFUL BREASTS OR VERY LARGE CHEST FROM HYPERTROPHIC MUSCLES. WHY NOT DONE EVERYTIME AS TRAINED AND PRACTICED AS SPONTANEOUSLY AS POSSIBLE.
- ECM (EXTRACRANIAL MANIPULATION)
- SOMETIMES YOU INHERENT A PATIENT WITH POOR POSITIONING PRE-INTUBATION, AND THEN YOU CAN INSERT THE BLADE FIRST, THEN GET APPROPRIATE ALIGNMENT OF THE HEAD AND NECK, WHILE SIMULATANEOUSLY GETTING THE BEST VIEW OF THE VOCAL CORDS. ONLY THEN USING ELM (EXTERNAL LARYNGEAL MANIPULATION) TO GET THE BEST INTUBATION VIEW POSSIBLE.
- ELM (EXTERNAL LARYNGEAL MANIPULATION)
PROCEED WITH CORRECT STANCE, CORRECT PATIENT POSITIONING, CORRECT BLADE HOLDING, BLADE SWEEP, ECM IF NEEDED, AND THEN MOST IMPORTANTLY ELM, WHICH WILL SAVE YOU THE MOST TIMES AND GIVE YOUR THE LITTLE EDGE TO SEE MORE, IDENTIFY POSTERIOR CARTILAGES AND ALLOW FOR SUCCESSFUL INTUBATION. NOT CRIC PRESSURE NOR BURP MANUEVER.
- CHEEK PULL
SOMETIMES THERE IS ALMOST NO PLACE TO PLACE THE TUBE. PERHAPS YOU LEFT THE ETT IN PLACE FROM A PRIOR GOOSING, TO PREVENT FURTHER GOOSING. PERHAPS YOU LEFT A COMBITUBE IN PLACE AND DEFLATED THE PHARYNGEAL CUFF. PERHAPS THE TEETH APPEAR LIKE FANGS. YOU NEED TO PLACE THE ETT WITH STRAIGHT TO CUFF SHAPING, FROM THE MOST EXTREME RIGHTWARD POSITION TO AVOID PLACING THE ETT DOWN THE UNDERBELLY OF THE BLADE AND LINE OF SIGHT.
- USES OF A BOUGIE
AS AN INTRODUCER FOR ENDOTRACHEAL TUBES VIA THE TRACHEA, OR FOR TRACHEOSTOMY EXCHANGE, OR EXCHANGER FOR ANOTHER LARGER ENDOTRACHEAL TUBES, OR ASSIST A SURGICAL AIRWAY BEING PERFORMED.
- BEST PRACTICE ON HOW TO USE THE KING LTS-D
WITHOUT A C-COLLAR ON, WITH A C-COLLAR ON. PLACEMENT WITH AND WITHOUT COLD STEEL DL BLADE.
- WAYS TO USE THE AIRTRAQ
SUPINE, UPRIGHT AND FACE TO FACE, MAC VIEW, MILLER VIEW, INSERTION TOO DEEP, PULL HIGH AND VERTICAL, "GET USED TO A BETTER VIEW."
- TUBE INSERTION/HANG-UPS
NEVER HEARD OF A PATIENT IMMEDIATELY DYING FROM PUSHING THE ETT TOO FAR DEEP/RIGHT MAIN STEM INTUBATION. YOU CAN READJUST WITH AUSCULTATION, AND PULL BACK ON THE ETT. DOESN'T STOP YOU FROM GETTING A POST INTUBATION CXR, CHECKING YOUR CAPNOMETRY, AND PULSE OXIMETRY.
IF THE BOUGIE HAS BEEN USED, SOMETIMES THE DIAMETER OF THE ETT IS FAR WIDER THAN THE DIAMETER OF THE BOUGIE USE. IT WILL BE DRAGGED DOWN BY GRAVITY, AND HANG-UP ON THE POSTERIOR CARTILAGES. PULL BACK THE ETT SLIGHTLY AND ROTATE THE ETT COUNTERCLOCKWISE, TO THE LEFT.
IF A RESCUE VIDEO LARYNGOSCOPY DEVICE HAS BEEN USED, HERPAS INSERTION OF ETT CAME AT AN ACUTE ANGLE, AND THE DISTAL TUBE CAN HANG UP ON THE TRACHEAL RINGS, ROTATE ETT CLOCKWISE, TO THE RIGHT.
- HOW TO CUT FOR SUCCESS
IS THERE A WAY TO TEACH SURGICAL AIRWAYS, HARDLY DONE BUT NEEDED IN TRAINING?
NO SELDINGER TECHNIQUE TAUGHT SUCH AS RETROGRADE INTUBATION OR USE WITH A MELKER DEVICE. NICE TO KNOW, BUT USEFUL SINCE THEY TAKE TOO LONG.
BOUGIE ASSISTED CRIC, AND A CRIC KIT ALREADY PREPACKAGED TO BE SHOWN.
IF MAKING YOUR OWN SURGICAL AIRWAY KIT, AND A 6.0 SIZED ENDOTRACHEAL TUBE, SCALPEL.
IF THERE IS A LUXURY TO BE HAD, IT WOULD INVOLVE HAVING A TRACHEAL HOOK, AND TROUSSEAU DILATOR. ALONG WITH A CUFFED 4.0 SHILEY. THE SHILEY IS MORE FIXABLY, AND LESS LIKELY TO FALL OUT THAN THE 6.0 ETT.
- THINGS NOT TO DO: DIGGING
- THE NOVICE INTUBATOR WHEN HE GOES DEEP WITH THE DISTAL TIP OF THE COLD STEEL DL BLADE, WILL LIKELY IF GONE TO DEEP THE ESOPHAGUS. IN TIMES OF STRESS, MISTAKES ARE MADE, AND THE RUSH TO FIND A A GLOTTIC OPENING BECOMES PARAMOUNT. LIKE THE TV CHARACTER HOUSE SAYS, ALL PATIENTS LIE. IN MEDICINE, YOU WILL ALSO REALIZE, DOCTORS LIE, INTUBATORS LIE. BETTER TO GO SLOWLY, RECOGNIZING YOUR LANDMARKS OF EPIGLOTTOSCOPY. VERY UNLIKELY TO INTUBATE THE ESOPHAGUS THIS BETTER WAY.
- THINGS NOT TO DO: FISHING
- WE ARE NOT TALKING ABOUT FLY OR BASS FISHING. THIS IS ABOUT TRYING TO CAPTURE "THE GLOTTIC OPENING" WITH THIS TECHNIQUE. WHEN YOU HAVE TO SUPRAGLOTTIC DEVICE NOR CONFIDENT IN YOUR SURGICAL SKILLS, ONE NEEDS TO DO WHAT IS BEST. HOPEFULLY WE CAN AVOID THIS TECHNIQUE.
- THINGS NOT TO DO: ROCKING
POOR TECHNIQUE AND TEACHING LEADS TO THIS. A BAD TEACHER REGARDLESS HOW UNINTENTIONAL IT IS, WILL BE RESPONSIBLE FOR A BAD STUDENT OF AIRWAY. LET'S AVOID THE DENTAL TRAUMA AS IN THE MOVIE HANGOVER ONE. WHO WANTS TO LOOK LIKE THIS GUY.
- THINGS NOT TO DO: LEVITATION BY BRUTANE
- HOW MANY PUSHUPS YOU CAN DO, OR HOW MUCH YOU BENCH SHOULD NOT BE THE NECESSITY TO INTUBATION. CLICK ON BRUTANE AND SEE WHAT HAPPENS AND SHOULDN'T HAPPEN.
Airway One
56-45 Main Street
Flushing, NY 11355
United States
ph: 347 724 4244
alt: Attention: Jose D. Torres, Jr., MD
drjdt26
