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Category: Anesthesiology

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.   A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the…

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JAW THRUST MASK GRIP

JAW THRUST MASK GRIP

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, spraying bloody froth on those nearby. The chest does not rise and the saturation is dropping. You want to help. Let’s address some questions that come up on this topic:   What is the problem when air leaks in face mask ventilation? When…

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USE THE SWALLOW PROVOCATION TEST TO ASSESS AIRWAY PROTECTION

USE THE SWALLOW PROVOCATION TEST TO ASSESS AIRWAY PROTECTION

A patient presents obtunded. You wonder about airway protection and consider intubation. Is there any way at the bedside to gather more information before choosing to intubate?   This has not been well studied in the ED population mentioned above, but if you are wondering whether the patient is going to aspirate oropharyngeal liquids, you could consider a safe trial of seeing how they handle liquids.   Called the “swallow provocation test” it is done by injecting a “swallowful,” (ie…

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SUPINE POSITIONING CAUSES AUTO-PEEP

SUPINE POSITIONING CAUSES AUTO-PEEP

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 all known to have expiratory flow limitation when laid supine. They do not exhale all the way. This is air trapping, small airways are occluded.  The simplest way to think about it, and perhaps there is more to it, is that the diaphragm is compressed by abdominal contents. Supine,…

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DIFFICULT AIRWAY: MODIFIABLE?

DIFFICULT AIRWAY: MODIFIABLE?

A patient presents in cardiac arrest, morbidly obese, her face covered in blood and vomit. As the paramedics bag her, froth sprays out to the sides. You place an oral airway and 2 nasal trumpets, while the resident pulls a jaw thrust and the ventilations get better. On a tough intubation you want the resident to have the best shot at first pass success. What can be done at the bedside?   This is a difficult airway, no doubt, but…

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NEONATAL INTUBATION: POSITION FOR AN ANTERIOR AIRWAY

NEONATAL INTUBATION: POSITION FOR AN ANTERIOR AIRWAY

Case: No time, no visible larynx You are seeing a patient in the hallway when suddenly a mother rushes in with a pallid blue lifeless infant. The nurses start CPR and bag mask ventilation as you grab a Miller blade and 4.0 tube. Your first look is all secretions. After using the adult Yankauer suction you clear that out fast and look again….esophagus. You pull back but still the larynx is nowhere to be seen. What do you do next?…

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