VentMedic Posted July 12, 2009 Share Posted July 12, 2009 (edited) We don't get to do rotations in the OR as EMT-I students here anymore for whatever reason. So goodness knows when I'll get my first live intubation. But I've been practicing the difficult airway scenarios so I can challenge the station for National Registry. Cricoid pressure has become my best friend. We were taught it for our EMT-B so, at least here, anyone on the medic or fire crew should be able to do it for you. Same for in the OR or ER. Next time if you are having trouble visualizing the cords ask some to help you out with cric pressure. From what I've been told the benefit of it on a live patient is even greater than on a dummy. And, no, you won't look silly or incompetent for asking. I wondered about that and was told you will actually gain more respect because you don't let your pride or insecurity compromise what you need to get done. Just a thought. Don't forget cricoid pressure (Sellick) is contraindicated in patients with suspected cricotracheal injury, active vomiting, or unstable cervical spine injuries. You've also got: OELM: Optimum External Laryngeal Manipulation BRUP: Backward, Upward, and Rightward Pressure As well, you can practice difficult airway scoring on friends and familly or just by people watching at the mall. Edited July 12, 2009 by VentMedic Link to comment Share on other sites More sharing options...
chbare Posted July 12, 2009 Share Posted July 12, 2009 In addition, cricoid pressure DOES NOT improve the POGO score/glottic view/Cormack & Lehane score. If you dramatically improve the glottic view by applying cricoid pressure, you are most likely performing ELM. Cricoid pressure involves locating the cricoid cartilage and applying pressure in an attempt to seal the esophagus and theoretically prevent passive regurgitation. This involves proper identification of anatomic landmarks. The most prominent structure is the laryngeal prominence, AKA Adam's apple. This is part of a large cartilaginous structure known as the thyroid cartilage. This is NOT where you apply cricoid pressure. However, many people in fact use this land mark and apply pressure. What we are looking for is the cricoid cartilage. Just inferior to the thyroid cartilage is a little valley known as cricothyroid ligament and membrane. (The area we use to perform a surgical/needle cric.) Just inferior to the valley is a smaller bump. This smaller bump is the cricoid cartilage. This is in fact where we go to properly perform cricoid pressure. With that, in many documented cases, cricoid pressure actually worsens the glottic view. In some cases, you may need to release cricoid pressure and manipulate the thyroid cartilage in order to obtain a better glottic view. This procedure is known as ELM/BURP. Take care, chabre. Link to comment Share on other sites More sharing options...
Jeepluv77 Posted July 13, 2009 Share Posted July 13, 2009 I'll have to look into these other procedures. We haven't gone over any of them and I'm hoping to test National on August 7th. We've actually only had 30 minutes of training on difficult airway. Not counting the 30 minutes of lecture. As for the scoring, something about Malla...something score(used in the OR was mentioned for about 45 seconds in class but we were told not to worry about that as it didn't apply to us. I've started to notice I'm probably not getting as much training as I'd like to have. Hence stopping at EMT-I for now and completing my Paramedic through my city's training academy when I can be sponsered or find the funds. Link to comment Share on other sites More sharing options...
VentMedic Posted July 13, 2009 Share Posted July 13, 2009 Malla...something score(used in the OR was mentioned for about 45 seconds in class but we were told not to worry about that as it didn't apply to us. I've started to notice I'm probably not getting as much training as I'd like to have. Are you serious? They don't teach how to identify a difficult airway? There are certain factors one must be aware of which will prevent you from making hamburger out of the airway which could result in a cric, trach or permanent damage to the voice. Link to comment Share on other sites More sharing options...
chbare Posted July 13, 2009 Share Posted July 13, 2009 In addition, a proper airway assessment may keep you from choosing to go down a path where doom is inevitable. The Mallampati assessment is only a small part of the airway assessment. I say airway assessment and not difficult airway assessment simply because every patient should receive an assessment to identify the potential for a difficult airway. A general assessment includes the LEMONS assessment. L: Look for gross external anomalies and the presence of a beard E: Evaluate the 3-3-2 rule M: Mallampati assessment O: Obesity/Obstruction assessment N: Neck mobility assessment S: Saturations Difficult BVM assessment: B: Beard O: Obesity N: No teeth E: Elder S: Snores frequently Difficult Cric assessment: S: Neck Surgery H: Neck Hematoma O: Obesity R: Neck Radiation therapy T: Neck Trauma Clearly, a complete assessment may not be possible for every patient; however, making as thorough an assessment as possible is paramount. This comes as no surprise as I had absolutely NO airway assessment education when I went through an EMT-I program a few years ago. Take care, chbare. Link to comment Share on other sites More sharing options...
WolfmanHarris Posted July 13, 2009 Share Posted July 13, 2009 (edited) Are you serious? They don't teach how to identify a difficult airway? There are certain factors one must be aware of which will prevent you from making hamburger out of the airway which could result in a cric, trach or permanent damage to the voice. It's really frustrating that we use American pre-hospital research that's potentially based on providers with piss-poor education has an affect on how things are done up here. I received more education on difficult airways then that, and it's not even in my scope. @JeepLuv If it's not too late to get your money back and start again, I'd consider it. At the very least, do your patients a favour and don't touch a tube; stick to an OPA or supraglottic as based on your own description of your education you're not competent to intubate. Edited July 13, 2009 by docharris Link to comment Share on other sites More sharing options...
AnthonyM83 Posted July 13, 2009 Share Posted July 13, 2009 In addition, a proper airway assessment may keep you from choosing to go down a path where doom is inevitable. The Mallampati assessment is only a small part of the airway assessment. I say airway assessment and not difficult airway assessment simply because every patient should receive an assessment to identify the potential for a difficult airway. An uneducated question, I suppose, but how does the score change your actions? Every action I can think of, is something that would be done/prepared anyway, with a "non-difficult" airway. Link to comment Share on other sites More sharing options...
chbare Posted July 13, 2009 Share Posted July 13, 2009 A mallampati by it's self may not change my practice; however, my plan may change after a complete airway assessment. If enough red flags are raised, I may not even intubate. Perhaps I will call for anesthesia or use basic manuvers until I reach the hospital, or I may look at an awake technique such as NTI. Yep, flight nurse chbare would actually defer advanced airway techniques based on assessment findings. Just did it the other night. The assessment effects my choice of airway pathway utilization. One of the biggest sins in airway management is doing something like a RSI when everything is screaming " don't do it." Link to comment Share on other sites More sharing options...
mobey Posted July 13, 2009 Share Posted July 13, 2009 A difficult airway may be the determining factor between RSI & RSS. I may hold off on the paralytics and stop at the benzo's/Fentanyl which can easily be reversed Link to comment Share on other sites More sharing options...
VentMedic Posted July 13, 2009 Share Posted July 13, 2009 (edited) An uneducated question, I suppose, but how does the score change your actions? Every action I can think of, is something that would be done/prepared anyway, with a "non-difficult" airway. To many fail to recognize a difficult airway and just do the poke and jab method until the airway is mangled. Then they plop the patient in the ED with a bloody and swollen airway. The ED staff of course will now have serious a problem to deal with while the EMS crew snickers that "they can't get it either". What they don't realize is that if they had recognized this earlier, the damage could have been avoided and a less serious intubation alternative might have been used as well as saving the patient many vent days. Often a patient may recover from whatever caused the respiratory problem such as COPD exacerbation or CHF quickly to where they should be off the vent in 24 hours. However, if the throat is damaged and the patient fails a leak test, they could be on another week or two or until they get a trach and/or peg. The unfortunate thing is some did not understand the anatomy of a difficult airway to even describe what they saw when attempting to intubate. Others may not admit it took them 6 tries with the tube and will also not tell the ED staff of potential problems although the ED will do their own assessment. It would however be nice to know a few things that could have been seen easier before the tube. Even when we get a patient from the OR in the ICU we look at the notes from the anesthesiologist just in case the patient may need to be reintubated in the future. Edited July 13, 2009 by VentMedic Link to comment Share on other sites More sharing options...
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