How to Intubate

hi my name is andrea herbert m.d. and i'm here to talk about airway and intubation okay welcome to intubation so today we're going to go through my way of doing a step by step or tracheal intubation so this is oral intubation we're not gonna do nasal we're gonna talk about the step by step checking the equipment checking that everything you have is prepared I want to go over the dexterity of how I think the best way to hold and position your hands and doing manual dexterity because oral intubation this is a really I hand motor activity so I'm gonna tell you how I like to intubate how I've taught medics over the years and it's generally been well-received and it works for me so there you have it so first thing is you're checking your equipment so your equipment is your safety so if you've checked your equipment and preparation is key so I say prepared to succeed so basically what I'd like to do is the same way every time intubation is a life-saving maneuver orally intubating somebody is going to make a difference in saving their life if you do it correctly what gives me comfort in a very stressful situation is to know that my equipment is in the same place every time I've checked it the same way every time I grab the same equipment every time you're gonna find out what size blade you like and what kind of blade do you like so I'm just gonna go over some basic pearls and words of wisdom for doing an intubation so here's your airway role you want to have different sizes of et tubes available different sty let's available there are all flexible sty let's and we'll talk about that a little bit more you have a handle and different choices of blades there's curved blades and then there's straight blades so we're going to talk about it a little bit more in the so a straight blade is also called a what Miller good and a curved blade is also called a Mac or Macintosh okay so I'm not here I'd have no investment in either one you need to try and practice on both definitely on the manikins practice of both it'd be ideal if you can do intubations on live patients with both I learned very early on that a curved Mac for is my go-to and you'll hear from Ryan Wyatt and I believe that's his as well too and I really admire him tremendously and he's an excellent in debater so a lot of us in emergency medicine really like the 8 sorry the 8 remember I said a do ET tube is for a man so a curve for Mac blade and what do you see that's similar about the Mac that may be why it's ideal for intubating looks like a tongue right so perfect so it follows the shape of the tongue okay it's really good for getting a big tongue out of the way now a straight blade or a miller definitely has its manages to I will tell you this most anesthesiologist a Miller a big Miller is their go-to blade in a difficult airway when they come to the emergency art mint they give me a big Miller okay so they like that because they really like to just yank the entire structures the tongue everything down to lyrics out of their way and a straight long straight Miller can really lift everything up and make the cords up here it doesn't have the advantage of curving along the structure of the tongue so to speak but it does lift everything so so just so you know so practice with both I like a curve for because I can get just about anybody intubated with a curve for Mac blade okay a smaller mouth I'll go for a three you can see the size difference okay so when I'm checking my equipment so I said you have eighty tubes ready you have style that's ready you have a handle okay the way you know the handle is working and the blade is you connect them okay you want to see your light that it's what light is white right tight connection okay don't pinch your fingers here okay we're gloves when you're doing this okay and make sure you leave the light on long enough if you're in a dark area or whatever make sure that the or I should say if it's bright it's harder to see if the light is bright but really make sure the light stays on sometimes the light will blink in and out and then you have to check to see and get another blade and if that doesn't work then it's maybe it's the handles fault so you have to see if it's a blade problem or a battery problem in the handle okay so you check and this is fine so this lights staying on so I'm good to go so you never do this so you've checked your light and you feel like it stayed on bright tight white long enough you never do this okay I don't care if you're just ready to intubate right now you don't that's poor technique okay you close it okay you don't leave the light on okay because that's wasteful and if it turns out to be a very difficult intubation and you're in there a long time then you've now limited if that light stays on for like a minute or two you've now limited the lifespan of that bulb during your intubation because the worst thing is is to lose your light right when you're searching for the courts especially in a difficult intubation so I checked that I have the right blade the right handle the light is good I have a good connection I put it down I told you I use for all men and here I have a male mannequin I'm gonna give him an 8 ok so if you're handed an 80 tube like this you can choose how you like to curve it I like a gentle hockey stick okay that works really well for me I think that is to angulated and to severe analyze speak up anytime is that what you is is what you like a curve hockey thank you must have been trained well okay so I like some people will go like straight angle out like this a 90 degree I think that's very pokey and I don't like that so I like to just have it like curves so it's not in my way and I like a right angle like that okay so it's not going anywhere okay you'll go over in the video at least a centimeter to a centimeter half the tip of the stylet from the eyelid or the end of the 82 okay so if I do a good 90 degree angle there's no way that this is gonna migrate through the tip of the ET tube and potentially hurt the soft tissue of their distal trachea okay so then there's the balloon so I've looked at my ET tube I like my hockey my hockey stick configuration I like my malleable stylet it's not going anywhere then I check my balloon so if the cuff is already deflated you get a 10 cc syringe and you get a nice tight fit and you blow it up now you'll see that that didn't make this tight all the way so you have to get some more air into it and blow it up until it's taut come out some et tubes even though they're brand new they may have a little tiny microscopic leak in the cuff it's called cuff leak so what you want to do is not just blow it up and then deflate it and say oh it looks good it's like blowing up a balloon oh it went all the way up and now let's take it down now you want to feel it and you basically gently pinch and there should not be a Shh you know like feeling a balloon where you feel a balloon and you feel like some air is coming out of it so it should stay taut like it is here so as such this is perfect okay um you're not gonna really hear the leak you're gonna maybe feel it and it gets softer and not as tight and then that means there's a microscopic leak okay so I'm comfortable with the amount of air that there's not a leak and then I get my syringe decompressed sorry decompressed and take all the air out okay and like such so you get all the air out then fill your 10cc all the way this is a stressful situation and you want it everything ready you don't want to have to oh shoot I forgot to I forgot to have my syringe filled up with air so it's like one step if you're ready to intubate and you realize you have a decompressed syringe a texture ET tube and that's one step now you're stressed out and you're disconnecting and you so have everything ready or if your assistants handing it to you they should hand it to you as such okay ready to inflate and go to Lube or not to Lube okay so if you're going to lubricate the cuff okay I would recommend doing that in a patient is dry mouth who do we have what population do we have significant percentage of the year in southern Arizona dehydrated right dehydrated patients whether it's border crossers dehydrated patients we have quite a bit okay their mouths are gonna be dry as dry can be I would recommend you lubricating when you lubricate the end of an ET tube you are not lubricating down here at the tip okay that's not where it needs to be its lubricating the cuff very small amount of sterile lubricant and you just coat it lightly it should not be glopping it should not be dripping it should not be big squirts of it on there because where does that lubricant gonna go where is that surgilube gonna go it's gonna go in the lungs okay and that's not appropriate okay so it's basically just a glistening layer so that the ET tube does not get stuck on the tongue or the soft tissue as it's migrating past the tongue going to the cords promised land where it wants to be okay so you're gonna have your BVM this is something you're doing before you're ready to intubate so patients should already be on non-rebreather and then put on and on for a non-rebreather or you go ahead and start bagging the patient okay depending on what the situation is so I don't have a BVM but you're doing good seal good BVM respirations so for your equipment if you suspect that there might be a foreign body you need to have Magill forceps available certainly is somebody that went into sudden respiratory distress particularly a child that was awake and playing and all of a sudden is unconscious or in respiratory distress but not unconscious yet you better be thinking of an acute foreign body obstruction a toy a piece of food whatever so have McGill's ready in any kid with respiratory distress it's critical also if you look at a patient and they are dentally challenged they have teeth that are loose that you think may be knocked out I would have McGill's ready okay so you have that ready in case a tooth accidentally gets dislodged okay so as regarding that was prepper so stage 1 preparation so I've prepared obviously suction is going to be hooked up either to a suction portable suction or first in the merge Department we have wall suction I like to have everything on my right so I have suction on my right I have my equipment on the right that I grab for okay the monitor can obviously be on either side if I have a respiratory therapist I'll usually have them on whether its side is less crowded and such but I always had the suction on my right hand side so if I'm intubating in a stressful environment on the floor on a bed on the on the ground wherever in the cafeteria that I always know that if I had a portable suction they would put it on the right hand side and that's where I'm used to having it so no matter what stress I'm in I know where my equipment is so have everything ready so I'm going to intubate him with a curve for Mac blade and my 8o ET tube right here so I have everything ready so when you're ready and I'm going to do it without the mannequin first so you can see my techniques I want you if you're standing and doing your first innovation in the emergency department or if you're in the field on the ground with the patient I want you to think that their head is here and you're standing at the head and think that you want your angle of how you're holding your hand on the blade sorry your hand on your hand on the handle that you want this to be in a 45 degree direction away into the world okay your world could be in the emergency department in one of our ER rooms your world could be in the back of a truck your world could be in the bedroom of the patient's house when they're found on the ground next to the bed unconscious unresponsive but I want you to think 45-degree direction of your thumb is part of the handle and it's going 45-degree direction away from you because if you do that you're going to find the cords and you're not going to rock back and injure the teeth and it's not so much that I don't want teeth getting injured it's the fact that if you're injuring the teeth that means you're rocking back and you're not finding the cords so it's improper technique and not getting you where you need to be and the teeth are the victims or the byproduct of you not getting where you need to be okay so when you're ready when you have everything ready it is best to try to do intubation with both hands okay in the beginning you might be stressed and you might want to manipulate the head and have somebody hand you the ET tube I think that's fine okay if you're intimating with me I will definitely hand you the ET tube I will definitely help you okay so some people it takes a while before they're ready to manipulate the head open up the mouth and do all that while they're holding the ET tube at the same time and I get that that's totally fine okay so when you have the head obviously we talked about before you're gonna look at what makes a difficult Anatomy for the airway you're gonna do what you can do to try to open the airway and improve your chances of success okay so if it's a non trauma patient you're gonna do what to their head and their jaw you're gonna do head-tilt chin-lift okay and you're gonna find that especially in a patient that's decreased level of consciousness or certainly unconscious where you pull their jaw they're really gonna stay that way okay so so you pull out their jaw as much as they can and then I like scissor opening of course with gloves okay so anytime you're touching somebody's mouth you're obviously wearing gloves and you have to be careful if you're not comfortable touching inside a patient's teeth but a scissor opening really does help open their mouth okay so scissors are opening you're crossing your fingers and it's really something you kind of have to see or you can do it that way but you really get more bang by just opening with scissors or you can actually just pull down their jaw and like I said generally it will stay that way okay you're a first gonna of course remove their dentures anything that comes out easily you're never gonna struggle and try to rip out a bridge or anything like that because you think you have to get everything out before you or olanta be if it comes easily you take it out if it does not leave it in okay and be very careful some of these will cost like thousands of dollars so you do not want to hurt their bridge so you've looked and you've opened their mouth you've suction them as appropriately not aggressively but suctions so that you have a nice clean dry pristine mouth to go into okay recognizing if they have a big tongue okay so the technique is this so when you're ready to go in that's when you turn your light on okay you're ready to go in the head is here everybody does it the same way it's uniform that you hold the laryngoscope with your left hand the tube with the right hand whether you're right-handed or left-handed do not hold like this okay you've lost your dexterity if you're holding too much on the blade definitely don't do this and I see a lot of people do this in the beginning they think their whole hand needs to be on the handle it's really right there in the middle this is like the crotch of the laryngoscope blade and handle I like to have my hands right there and I make my thumb part of the handle so that this is all one unit and this is so helpful if you're innovating in the back of the truck without me even being in the back of the truck I know this is the way to do it because if the truck is moving you're going faster going code three if the if you are moving your whole hand and the blade moves as a unit if you're like this you're going to knock it inside their mouth and damage teeth and damage the mouth because you're you're jerking with your wrist on your hand is causing damage inside because you don't have good control over the blade inside the mouth so best control is if somebody knocks me very little movement because I don't have a vise grip but I have a secure grip because I'm gripping at the union of the handle and the blade does that make sense okay so think of it this way that you are as a unit you are holding it at the crotch of the blade and handle nice and secure and when you go into the mouth after you've done your scissor opening its mouth should stay open you open the right corner of the mouth and you sweep to the middle almost always every paramedic on their first attempt to intubate goes straight into the mouth okay they're excited they're stressed it's adrenaline situation and they think blade needs to go into the tongue okay but actually what's gonna happen the tongue is gonna flop right into your view it's gonna flop from the right or its left-right and view and block your view of the courts so you have to start in the right corner of the mouth and that's the same with the Miller as well you need to do with the Miller as well start in the right corner of the mouth and sweep to the middle and remind yourself that it's a 45 degree direction away okay so there should never be any rocking back of your wrist if you do that you're gonna hear the click on the mannequin you're gonna hear you're hitting the teeth in the field I'm gonna tell you I'm gonna be looking right in the mouth and say on the teeth you're on the teeth you're on get off the teeth get off the teeth because you're looking for the cords whoever your supervisor is is seeing where you are oriented in the mouth okay and you have to be mindful of where you are in the mouth on babies and toddlers they won't have teeth so when you rock back you're gonna injure what their gums and you can cut and tear their guns okay so there's never rocking back of the wrist you keep your forearm and you're all the way through your wrist is as a unit keep it locked doesn't mean you're like an advice grip but you really keep it at a 45-degree angle and you don't have to have a strong forearm strength as you can see I don't have a well-developed forearm strength but I'm a really good intubate ER because I know not to do this and I know to keep keep this all solid as one unit question it's just it's a standard that's just accepted across emergency medicine and anesthesia so also good point that you see here you ask the question the laryngoscope blade is so that do you see this so that the laryngoscope blade is is structured so that the ET tube is sliding down the middle so it has to approach from the right to go in as such so it's the way the ring skull blades are designated as well so that's really the main reason so by conformity is why it's that way so right corner of the mouth okay so the blade right corner of the mouth you almost always have to go in a little bit further and you are going to do motions that are going further down not rocking back okay and never jabbing okay and it's a little easier to show on a mannequin than my hand suspended in midair the key thing is that the 82 follows what you just did with the lowering disco blade corner of the mouth and advanced it if you go straight in like this you've now blocked your hard-fought view of the courts so again corner of the right side of the mouth sweep it right into view of the cords do not advance the ET tube unless you see the cords you might not see all of your view of the cords if you see limited you're gonna see the posterior okay because they difficult Airways are more anterior and that's when you have to rely on somebody giving you more crike pressure if you don't see a full view of the cords so you go in and you never ever ever take your view off the cords so you don't need to talk to the driver you don't need to talk to somebody to say hey you have suction ready for me right oh crap I just lost my view of the cords okay or say you drop this oh oh crap I just lost my view of the cords somebody is there to help you don't look for the suction that's what I see people make mistakes they go looking for suction they drop their ET tube or they want to hold it they wanted to open the mouth a little bit more I can't find it oh here's or be a good assistant I've had so many people over the years hand me an ET tube like this so don't do that hand it to them and their hand is out like this right in like that go so hand it to them the right way okay everybody knows hand it to me the right way hear me McGill the right way I don't need to look away if you hand it to me the right way so you go in and you never take your eyes off the course and neither could ambulance is moving you don't look away and it is uncomfortable okay if you can't get the intubation right away you still have to keep your forearm wrist and hand in a unit locked and loaded like that you just can't I'm getting tired and want to relax your wrist you can't do that or you will not find the cords and you'll hurt their mouth or the teeth so you you put it in and hopefully you have an assistant okay that is going to simultaneously to viii take the stylet out you can back out and that's another mistake I see you need to back out the laryngoscope blade in the same angle you went in so you win in a nice and gently you start at the right and swept to the middle you back it out gently you don't have to back it out to the right but some people just pull it out and they knock the teeth out on the way out that's not that's not right so you back it out and come out gently okay because everybody just wants to know if the tubes in the cords oh I got to see the end tidal co2 uh just come out real quickly and they don't think and they're hurting the patient so you take it out gently you're securing it's as hard to obviously to do all by myself but you have a ET tube in and somebody's taking the stylet out holding the ET tube in place this one's really rigid and at the same time inflating the cuff you might need to do it twice inflate some more air in the cuff and end-tidal co2 should immediately be available easy cap really nice and fast what's the color change mean what's good what's bad gold is good purple poor okay so yellow or gold is good how many breasts do you need to have reliable good color change how many at least three to five breaths it really should be at least five okay the more the better in other words okay so was I also gonna say so the securing in the field you're going to have you're going to have marketed tube securing devices in the ER we have respiratory therapy do it with taping the tube and you can watch them do that so means of confirming that you are intubating the patient correctly that there's good ET tube placement in the trachea not an esophagus what's the number one most accurate way that you can confirm your ET tube is in the trachea capnography okay if you don't have a capnograph er easy cap is just is just fine - okay capnography is better because it's measured electronic data around easy cap easy caps can be old they could have malfunctioning from the manufacturer the chemical could be old or desiccated and not change color if you think you did an excellent education and you saw the ET tube go through the cords and your easy cap is reading purple I would suggest you get another easy cap okay break up another bag it's fine in general I'm going to tell you this do not take out an ET tube that you witnessed it go through the cords and you did not have any suspicion it was dislodged you can put a tube through the cords and then all of a sudden the ambulance takes a big turn and you turn and you you know you hadn't had it secured yet and your hand pulled back and you'd pull the ET tube back or unfortunately I see the medics when they're transferring the patient from the ambulance gurney to our stretcher in the emergency department that tubes get dislodged then okay they're like who's got the tube oh I've got the tube and somebody grabs the tube as the patient's being transported over to the bed and all of a sudden the tubes like hanging out this much and I'm like oh my god you know you guys nobody's secured the tube okay so it's moot patient movement or your hand moving when you reach for something you had a hand on the 82 but you reached or something and you didn't realize that part of your body stretched when you reach something in the truck and so that's how tubes it's not meant to be it wasn't intentional most of the time but it happens that tubes get dislodged and they maybe just get dislodged where the balloon goes just right above the courts but or an or it goes what higher up in the oropharynx and that's not where we want it to be okay so we want the balloon past the cords alright so fogging up the 82 is good to note and important medically legally that you see fogging of the ET tube okay breath sounds bilaterally equally over both lung fields you need to document no breath sounds heard we're over the stomach or epigastrium right okay those are all important but the most accurate medical legal definition of a secured endotracheal tube is entitle co2 capnography better than easy cap okay quick question so you did you talk to the order you know you get in you pass the chords and then you secure and you touch on for them when they let go right so it's hard with me button by myself but here but it's kind of all I want you come up here with me so so when you are inflating there's three things that need to happen kind of at once because if you have help you can really do it all at once so you're you've got the blade in you've got the ET tube through the cords you can have if you're by yourself a lot of people hold to and Ryan will show you some techniques cuz he's by himself obviously a lot in the in the helicopter said that you blow it up and then you get rid of that and you can hold them both together so you definitely need the balloon up okay you're not gonna be able to feel it when it's in but you need the balloon up and you do not take the stylet out until the balloon is up all the way so always think I see the cords I blow up the balloon and then the rest kind of happens at the same time that the stylet comes out and you want to hold that like that you want to hold this stylet I mean the right here like that year so I'm in and the book and the ET tube is in and I blew up the balloon so coming out and taking the stylet out it's pretty much at the same time I certainly usually come out first because it's so crowded in there and there's many hands in there so it helps to get the luminous scope handle out first so I come out I close this off and then usually like I said I have a ton of help but somebody holds the ET tube and takes the stylet out okay so that actually kind of can happen simultaneously but what can't happen this has to go first okay so you think about it if you're pulling out a stylet out of an 82 but you don't have the balloon up what can happen you pull the tube out on top of the cords okay and then you realize it then you blow up the balloon and then the balloon might be above the courts or at the level of quarters and will hurt the cords if you blow up in there so just be gentle getting the stylet out it usually out pretty readily and another trick of the trade is when you're holding an 82 I'll just have you be ready for my system when you help me with the mannequin here that it is very important to watch where your hands are on the patient you need to be respectful and you need to not hurt the patient you don't mean to but I don't want to see any of this so you're getting ready to intubate the patient I don't want to see any of this like okay right everything ready you know and yours you know like this is not a table okay their faces are not and you'd be surprised okay their face is not a table it's not a landing place for your hands or your tools or instruments and stuff like that so what you can do is you can have your hands around their face and definitely be ready okay and let me get my hockey stick back again I'll do it on the main mannequin here and so you can definitely be ready so I've been begging the BVM comes off I'm not a trauma patient here so I'm going to really try to hold the head down and I think I'm gonna have to actually help you hold it you have to hold it so I have really good head position I'm ready to go I've got all my equipment over here I've like everything I have over here so I do my scissor opening with my hands and I don't you I see medics in the field that they'll tell me they'll do this or whatever I think that's okay I just don't want like hey you know what I'm gonna intubate you know elbows up on top of their eyes or on their face or whatnot so it's scissor opening okay inspecting the mouth do a last-minute suction suction suction again so you have a dry pristine field so steps are scissor opening light on right corner of the mouth sweep to the middle nice grip on the crutch of the handle my thumb is part of the blade I might need to go like this a little bit and I look and I look and it's totally fine to have your forehead on their face like this because this really as long as you're not directing pressure to their eyes so there we go so corner of the mouth mid line and it's in so I say to my assistant balloon up coming out gently I'd get the light off and this is what I want to teach you do not hold the ET tube up high here because all of a sudden your driver comes to a complete stop and you go forward and you pull the 82 about or you fall backwards and you pull the ET tube out even though the balloon is up let me just tell you that balloon is not much of an anchor okay it's gonna go wherever that hand is that's holding the ET tube trust me on this okay so you will have success about not dislodging a tube if you keep your hands pinched on the ET tube at the level of their mouth and that's perfectly fine to have your hands resting like this so a lot of medics a lot of doctors a lot of anesthesia they'll rest their hands like this the whole time to talk in they'll intubate and they'll talk to the surgeon and their hands like this the whole time so pinch on the face is fine but just watch your hands are not on their eyes or on their nose that kind of thing so pinch and then you ask your assistant can you get the stylet out please okay seeing that this one's really stuck I need two hands on this one it's not really like that in the real life okay but you got to watch what you're doing and people will sometimes really get very lacs about holding the ET tube and it's a shame when it gets dislodge because you just did all that work okay so then you should immediately have the easycap already hooked to a BVM so it is seamless that you have hooked this on and this should be attached to the BVM so you put it on and how many breaths at least three or five okay and you want to see fogging of ET tube you want to see chest wall rise and fall equally no breath sounds over the stomach rep aghast reham you want to see yellow color change and you want to inspect to make sure you didn't hurt the patient okay I didn't click the teeth you didn't hear any clicking right so your assistant can also be looking to make sure I don't know if you look to see how far away I was from the teeth but it was not anywhere near the two so look to see cuz sometimes unfortunately I have hit the teeth okay I've hit the teeth in patience I have very small mouth opening it's a critical situation they don't need to be crike just because they have a small mouth it's just you have to I just have not a lot of movement in the mouth and I just have to make sure I get it or I'll see you know I have to call anesthesia or do it glidescope actually helps reduce that problem because you don't need a lot of mouth opening with the glidescope so really try to keep hands down low okay no jerking jabbing so I don't want to see any of this can't I can't see the cords I can't see and you'll be surprised and it's not really that rough but I do see kind of jabbing alright so when you go in you don't see it mommy I guess I have to take this out can you take the right so if you don't find it you go in there and you almost don't ever find it let me just get this out almost always your first attempt like this first attempt I'm at the base base of the cords and then I go a little bit further in okay so migrate it down and 45-degree angle away and think I need to go deeper and more interior but almost always cry pressure will help you find the cords so RT or your assistant and the truck say I need more Craig pressure okay and sometimes even they call burp so burper actually works really well it's backward upward rightward posterior or whatever so just putting a little upward pressure can make the courts pop interviews antecedent likes the burp so anyway and then you find the chords okay suction when you need to don't think you can always suction before or after there's plenty of times I'm in there and have a view and then I lose it because of pulmonary edema fluid or vomit so suction but again never take your eyes off the cord suction cake tube just okay so don't take your eyes off suction if you need to if you're losing your view somebody tells you the SATs are dropping get out okay you cannot let your ego get in the way it's very frustrating especially you think oh the docs only to let me have one chance and we say the SATs are 90 okay and I tell you keep going and then I say the SATs are 84 okay you need to come out you need to come out okay when the SATs are dropping patience not doing well it's taking too long aunt debate or the patient's deteriorating or both okay so if somebody tells you the SATs are dropping or they're developing a new arrhythmia you need to be mindful about that you need to park your ego and you need to get out and let so many more experience do it okay questions you have any recommendations for when they verbalize as they're doing what they're doing what they're seeing um I think that's fine for me usually it's um what do you see what do you see do you see the course do you see the course you see the course I think it's really it's it's vomit or it's blood or it's fluid or it's foreign body or pulmonary edema fluid that there's something above or they just usually just don't see the cords right away and a lot of it is because a lot of patients have to have their head really manipulated good and we have a trick that anesthesia in here doctors do is we roll up a towel and put it between their shoulder blades and that actually makes their cords pop out so so we'll do some tricks to make their cords come out so when I can't see the cords there's things that we do in ER so I will I need to know if you can't find the cords because maybe I can't either maybe I think it's an easy innovation you get in there and you can't find the cords and then I can't find either okay let's bag them up let's try some this roll them over let's put a towel between the shoulder blades and a lot of times that helps okay this is for doing a direct laryngoscopy like I said the glidescope is really making this almost obsolete okay because the glidescope really finds the cords for you if you only thought the time the glidescope lets you down difficult Airways bloody fluid filled Airways because you just can't because you're depending on a video so if your view is blocked by fluids coming up you have to suction as fast as you can see on that video it's often better to be actually in there yourself doing a direct laryngoscopy when there's a fluid filled field shall we say most patients are going to be between 20 to 24 centimeters okay so that's really important and I'm sorry I passed by that so you want to say how many you want it for documentation purposes what size tube and where the tube is at the teeth or at the gums or the so you can make a choice if they have teeth we generally by tradition say 20 centimeters at the teeth with a NATO ET tube no complications okay or if they don't have teeth then you say at the gums or at the lips but teeth and gums are a little bit more accurate because the lips obviously kind of move so yeah that's the standard so if you go and see your partner did intubation and you see this much you see it like really buried see just the this the cap of the ET tube so to speak at the level of the mouth and you know what that it's what right mainstem okay so that's also important so any intubation it's your job as a medic it's really not good care if you have not auscultate that patient before you've intubated them you need to listen to the patient's lungs before you intubate because you have to know what they are before so you know what they are after you've done an intervention and there's not much bigger interventions than intubating the patient other than cracking them putting a chest tube in or cutting open their chest or you know so that's a major intervention in the patient so you want to know what their lungs were like before you intubated them and therefore what afterwards okay because if their lungs were perfectly equal bilaterally and then it was your first intubation and you don't hear good lung fields over the left or just a bit diminished but they're good on the right you've probably right mainstem the patient okay and like I said it's not the end of the world but it's not perfect and we want it just make it a little bit more perfect very good question thank you I didn't go over that either so as soon as the ET tube you see it go past the cords stop and that will prevent you from right mainstem in the patient because I think that's what happens a lot of people are so excited or stressed they see the the cuff go past the cords but they think they've got to keep going and that's not you just go past the cords but making sure it's past the cords you know it's not like just a few millimeters like get it past the cords but don't go further that and a lot of people just shove you know and then it's gonna be right mainstem so it's a very good point so as soon as the cuff is past the cords you're good and if you're pulling up to the hospital the first thing we're going to do obviously checking ABCs and patients stable we're going to get a chest x-ray anybody that role isn't intubated we're already calling respiratory therapy and we're calling x-ray to get a portable chest x-ray and the doctor sees it within ten minutes so we'll know right away if the patient's right mainstem so really good points thank you yeah so in the field I don't prefer that us students that I don't want you manipulating the the tube in the field okay so that needs to be done by a senior medic and in the hospital you're gonna only do it under the supervision of a physician okay because it can be backed out too far so when we see it right mainstem on the chest x-ray or somebody from the field brings in a patient and I see that this is buried too to here I'm gonna pull the 82 back out some more because I know it's right mainstem weather I hear decreased breath sounds are not the tube should not be buried like that okay so so it is always deflated first so the two that balloon has to be deflated because you're pulling back so you don't do any manipulations with the tube forward or backward or anteriorly or post eerily without having the cuff deflated okay or else you could hurt the inner linings of the trachea hurt the tracheal rings so it has to be completely deflated and then you manipulate the tube and the respiratory therapists in the hospital they're the ones doing it the physicians can do it but usually with say two RT pull back the tube two centimeters it's right mainstem or it's at the Carina pull it back two more centimeters so is anybody know the perfect place for ET tube placement on a chest x-ray it's about two to three centimeters above the Carina in the distal trachea okay and that gives excellent excellent adequate excellent adequate oxygenation to both right and main right and left mainstem bronchi exactly where do you want to seat the tip of the mac blade when you go in okay so you want to as you're going from right to middle of the tongue and sweeping you want the tip to go down straight midline as far as you can go to reach the chords so you're hoping the tip whether it's the Mac blade or the Miller blade to reach just to the level of the chords it's usually it's just not long enough usually to go past or through the chords so it's designed for a length like this for a reason for adults and so the tip is really going to be just and there's a video that shows it better or actually it's on a cadaver that we'll get to this afternoon that the tip is really going to be just above the level of the chords so you have a view of the courts hopefully staying open because the patient is unconscious or because you've paralysed them and so that the chords are right below the tip of your blade and you can see it with your hand locked and you might get tired like I said I don't have much forearm musculature but I don't care if I get tired and I can hold my forearm like this for a long time if I have to do multiple intubations and I don't have any help dannis seizure in the middle of the night is doing a case and I'm the only one that can intubate in the hospital I've got to be the only one that can intubate in the hospital okay or correct them but I can't let myself get tired cuz when you get tired you get muscular fasciculations and that kind of thing you can't let yourself do that so you hold it locked in for as many times as you need to to intubate the patient and that you make sure that you go from the right corner of the mouth toward the middle and that you don't obstruct your view until you get the tip of the ET tube just at the level of the cords so you can see the tip passing through the courts and that has to be your documentation I visualize the 82 passing through the cords I say that on every patient okay or if I have a poor view then I'll be honest and I say I had a poor view of the cords limited view only the posterior cords but I slid the 82 past the posterior view that I had of the cords so that will stand up in court so in the pre-hospital setting if you do a visualization the cords you're not going to be through closed cords so you tell your supervisor I can't I can't pass the tube the cords are closed so it's usually going to be because the patient's breathing or they're in spasmodic closure so you're seeing them when they're breathing they just haven't opened up their cords yet often if you can wait a few seconds if they're waking up or they're awake then the cords will open back up but generally you're going to be only intubating patients that are unconscious or they're done through RSI from somebody else that is trained in RSI so generally that'll be in the in the emergency department more than it would be in the field what about anaphylaxis I'm swelling okay so in anaphylaxis and swelling you're gonna and we and we did talk about that so what size tube are you guys gonna grab for anaphylaxis okay you're gonna get a smaller one okay so a woman you could get a five and a man you get a six so two sides of the snore down we're half size or a couple half sizes so and you have to be in anaphylaxis you really get one shot okay like I told you about my trauma patient with the low renewal fracture that I the trauma surgeon was standing over and said you have one shot like meaning he really didn't even want me to try little confidence so you have one shot in trauma to the neck you have one shot in anaphylaxis smoke inhalation those are also been one of my most difficult intubations where they're really swollen and sit all the way down to their cords I've had to dig out suit too I've dug out sit with the Magill forceps I've made a tunnel and just burrowed and made a quick tunnel and took it out and then intubated through that of course I could have cracked them but I was pretty fast so I got it that way so there's different ways to do that certainly going straight to a crike one that would be fine too so be mindful of swelling be mindful that there's intubations that you're only gonna get one attempt and the most senior person to do it any other questions [Music] thank you thank you [Applause] [Music] you

Channel: Paramedics

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Id: yyAeoY7J77I

Length: 46min 44sec (2804 seconds)

Published: Tue Jan 02 2018