You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath. The chest does not rise and the saturation is dropping.


What is the problem?

Sometimes the problem is an insufficient seal around the mouth but more often the problem is soft tissue obstruction. We intubate supine. The tongue occludes the airway. The air follows the path of least resistance, which is out the face, leaking around the mask.


What are the choices of grip?

  1. One handed grip, aka C or CE grip (generally acknowledged to be less optimal).
  2. Classic two handed grip – taking the problematic one handed grip, and doing it with the other hand too. Similar to the grip you would have if holding a soda can.
  3. Jaw thrust grip – similar to the grip you would have if lifting a gurney or plank, thumbs on top, fingers below doing the work of lifting. Or if you will, taking your soda can and dumping it out forward.


Some studies say CE grip or jaw thrust grip are equally effective. So why do you say jaw thrust is better?

Most of the time airway resistance (A) is lower than mask resistance (M). Anything will work in that situation. What really matters is what happens when A is greater than M. That isn’t addressed in most of these studies.


What happens when A is higher than M?

When airway resistance is higher than mask resistance, the operator grips harder to raise mask pressure. The fingers often compress the submandibular space. This presses the tongue against the posterior airway, and raises airway pressure further. The harder you grip, the more you close off the airway.


What is a better way?


The best way to grip the mask is to press the mask to the face with the thumbs pointing forward. The fingers then fit over the angle of the jaw. If you want more pressure, you pull the fingers, which not only increases the seal pressure but also performs a jaw thrust maneuver. It pulls the tongue off of the palate.


Is there anything else that will help?


Place two nasal trumpets and an oral airway. Whether you have great technique or bad technique this will help. Don’t be afraid to “waste” some plastic here. I suspect that nasal trumpets also improve the effectiveness of apneic oxygenation via high flow rate nasal cannula.


Back to the case. You put the thumbs pointing forward on the mask and pull jaw thrust with digits 2-5. The leak is gone and the patient is re-oxygenated before your second attempt.



-Use the jaw thrust mask grip technique for ventilation

-Good mask ventilation is a crucial airway skill. Invest in it.

-If you are have ANY trouble, place nasal and oral airways


Suggested references:

Efficacy of facemask ventilation techniques in novice providers.

Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS.

J Clin Anesth. 2013;25:193-7



Anecdote 1:Don’t call it a seizure, start CPR

Resident: Hey, remember that patient in room 7 with the heart attack? Now he’s having a seizure!

You: That is not a seizure, let’s start CPR!

(the patient survives, and receives emergent catheterization opening a blocked vessel)


Cardiac arrest is often accompanied by jerking movements. The cartoons of the 1940s understood this. Bugs Bunny would typically do a few good jerking leg kicks prior to faking death with Elmer Fudd, Yosemite Sam, etc. If the setting is more appropriate for cardiac arrest, check pulses first.


This is probably not substantially different from convulsive syncope but I will describe that separately:


Anecdote 2: Don’t call it a seizure, refer to cardiology

“we never figured out why the Brugada syndrome patient had a seizure” –someone who should know better


Blood bank studies show that about 10% of syncope events are accompanied by a convulsion. These can look like epileptic generalized tonic clonic seizures. The differences are:

Pre-ictal: what were the setting, the symptoms, and the signs, before the event. An aura suggests a seizure. Standing in church suggests syncope. Alcohol withdrawal suggests seizure, etc.

Ictal: convulsive syncope is less rhythmic, less symmetrical, and less sustained

Post-ictal: Convulsive syncope patients regain normal arousal within a minute, seizure patients take 10-15 minutes


It isn’t a seizure until you have a diagnosis. It is a convulsion. Apply an appropriate differential that includes convulsive syncope.


Ancedote 3: Don’t call it a seizure, check the temperature

A middle aged patient is waiting to be seen for generalized weakness. The triage RN rushes them out of the waiting room because of a “seizure.” He never lost consciousness and was awake the entire time. Temp is 103 oral. You ultimately diagnose sepsis from pyelonephritis.


Rigors can cause tremendous shaking and can make us worry about seizure. Obviously a seizure can raise the temperature so judgment is required. But don’t automatically assume that a convulsion from sepsis is a seizure. Rigors happen when the temperature is rising, so recheck the temperature.


Anecdote 4: Don’t call it a seizure, educate the family

A patient is here for opioids. The doctor said no. She has a history of developing “seizures” when she does not get narcotics. Now she is screaming loudly and, wait for it…. The RN runs to you announcing a seizure and asks if you will give Ativan. Okay, I admit it, I often give Ativan if I am not sure. One time I went to the patient and said “really, you are having a seizure? Can I see the tongue biting, show me the tongue” and she proceeded to show me her teeth, biting the tongue.


This is tough. Don’t expect the family to understand the difference between seizures and psychogenic convulsions (also known as pseudoseizure). Educate them on the potential for psychogenic causes (but don’t prematurely rule out epilepsy either, unless it is abundantly obvious)



-Our terminology can box us in. Don’t call it a seizure unless you are committing to an epileptic etiology.

-Ask about circumstances before, during, and after the event to identify possible convulsive syncope


A patient you are caring for in the ED collapses. The nurses check pulses. One feels a pulse, one does not. Do you start CPR?

Studies do show that “feeling a pulse” does not mean a pulse is there. Many of these studies have significant limitations but overall they all seem to say the same thing. People feel pulses that are not there approximately 10% of the time.(Eberle Resuscitation 1996) One study in infants recommended using auscultation as more accurate than palpation.(Inagawa Paediatr Anaesth 2003)

We use unresponsiveness and apnea as adjuncts to recognize cardiac arrest. Apnea needs to be interpreted properly. An agonal gasping respiration raises the concern for cardiac arrest, rather than arguing against it. And respirations can continue for up to 3 minutes after ventricular fibrillation, so don’t be too rigid in using respiration to rule out the need for CPR.(Menegazzi AEM 1995)

How do we diagnose cardiac arrest? First, they have to be unconscious. Next, there needs to be some finding that indicates lack of perfusion. This can be pulselessness or apnea/gasping. Early on there is often doubt, but jump on the chest and start CPR if you don’t feel clear and obvious pulses.

Take Home Points:

-The pulse examination is not 100% sensitive or specific for cardiac arrest

-Given that we have to make decisions with imperfect information, it is better to err on the side of starting CPR

-Apnea is not 100% sensitive either, as respiration can continue for 1-3 minutes


Why do some critically ill patients, when they are laid flat for intubation, either get worse or sometimes even go into cardiac arrest?

Patients with CHF, COPD, and morbid obesity are considered susceptible. I am not sure what I have read in the literature is correct in explaining it. I suspect that anyone who lays flat has more air trapping. This can crowd out venous return. In a patient on the brink of dying, impairing venous return might put them over that brink.

An interesting corollary of this idea is that patients with high autoPEEP on a ventilator can be placed in the upright position and this significantly reduces their autoPEEP.

So in summary, supine positioning appears to exacerbate auto-PEEP, and in the peri-arrest state can precipitate cardiac arrest apparently through crowding out venous return

Take Home Points

-Supine positioning causes autoPEEP

-In the patient with a respiratory life threat, keep the patient upright as long as possible.

-Consider 30 degrees elevation (reverse Trendelenburg) for intubating patients thought to have potential for arrest during intubation

-In the ventilated patient who develops auto-PEEP, use reverse Trendelenburg or upright posture as a treatment

Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit.

Khandelwal N, Khorsand S, Mitchell SH, Joffe AM.

Anesth Analg. 2016 Apr;122(4):1101-7


A patient presents with hypotension after a syncope event. Clearly the issue was a temporary lack of perfusion to the brain related to the low pressure. But what caused the drop? The physiologic formula for blood pressure can help.


(CO = SV x HR)

The heart rate (HR) is normal. You see no evidence of sepsis and doubt the systemic vascular resistance (SVR) has dropped. Vasovagal reactions temporarily drop the heart rate or SVR, but this does not fit that, with ongoing hypotension. Something caused the stroke volume (SV) to drop. The laboratory results show anemia, and the rectal examination is heme positive. This is an occult gastrointestinal hemorrhage.

Take home points:


A drop in blood pressure suggests a drop in stroke volume, heart rate, or systemic vascular resistance