The Golden Hour > How Time Shapes Airway Management > by Charlie Eisele,BS,NREMT-P

Home , Bag valve mask, Golden hour (medicine), Oropharyngeal airway

September 2008

The A supplement to JEMS (the Journal of Emergency Medical Services) Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES Sponsored by Verathon Inc. ELSEVIER PUBLIC SAFETY

The Perfect View How Video Laryngoscopy Is Changing the Face of Prehospital Airway Management A supplement to September 2008 JEMS, sponsored by Verathon Inc.

4 Foreword > To See or Not to See, That Is the Question > By A.J.Heightman,MPA,EMT-P 5 5 The Golden Hour > How Time Shapes Airway Management > By Charlie Eisele,BS,NREMT-P

9 The Video Laryngoscopy Movement > Can-Do Technology at Work > By John Allen Pacey,MD,FRCSc

11 ‘Grounded’ Care > Use of Video Laryngoscopy in a Ground 11 EMS System: Better for You, Better for Your Patients > By Marvin Wayne,MD,FACEP,FAAEM

14 Up in the Air > Video Laryngoscopy Holds Promise for In-Flight Intubation > By Lars P.Bjoernsen,MD,& M.Bruce Lindsay,MD 16 16 The Military Experience > The GlideScope Ranger Improves Visualization in the Combat Setting > By Michael R.Hawkins,MS,CRNA

19 Using Is Believing > Highlights from 72 Cases Involving Video Laryngoscopy at Martin County (Fla.) Fire Rescue > By David Zarker,EMT-P

21 Teaching the Airway > Designing Educational Programs for 21 Emergency Airway Management > By Michael F.Murphy,MD; Ron M.Walls,MD; & Robert C.Luten,MD

COVER PHOTO KEVIN LINK Disclosure of Author Relationships: Authors have been asked to disclose any relationships they may have with commercial supporters of this supplement or with companies that may have relevance to the content of the supplement. Such disclosure at the end of each article is intended to provide readers with sufficient information to evaluate whether any material in the supplement has been influenced by the writer’s relationship(s) or financial interests with said companies.

Publication Information Vice President/Publisher T Jeff Berend T [email protected] Editorial Director T A.J. Heightman T [email protected] Supplement Editor T Lisa Bell T [email protected] Associate Editor T Lauren Coartney T [email protected] Art Director T Liliana Estep T [email protected] Advertising Director T Judi Leidiger T [email protected] Western Advertising Representative T Noelle Chartier T [email protected]

A Perfect View is a supplement sponsored by Verathon Inc.and published by Elsevier Public Safety,525 B Street,Ste.1900,San Diego,CA 92101-4495; 800/266-5367 (Fed. ID #13-935377). Copyright 2008 Elsevier Inc. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. Subscription information:To subscribe to an Elsevier publication, visit www.jems.com. Advertising information: Rates are available on request. Contact Elsevier Public Safety,Advertising Department, 525 B Street, Ste. 1900, San Diego, CA 92101-4495; 800/266-5367.

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 3 Foreword To See or Not to See, That Is the Question BY A.J. HEIGHTMAN, MPA, EMT-P

ndotracheal intubation has been considered the gold standard in airway management in EMS systems for decades. When I went through paramedic training in 1976, anesthesiologists—initially skeptical about endorsing the performance of this advanced airway skill in the prehospital environment— agreed to instruct us and allow us into the operating room (OR) to intubate their patients. Well, at least some of their patients.

EI remember gowning up early in the morning and to emergency departments (EDs), with more hospital meeting with the assigned anesthesiologist to go over scrutiny of prehospital airway care than ever before. the OR schedule and being told whom I could and What this all means is that fewer ET tubes will be couldn’t intubate. If the patient had a jutting jaw, a large placed in many EMS systems, those that are placed will neck, a history of cervical fracture or poor teeth, I wasn’t have to be accomplished with little or no interruption in allowed to intubate them and was required to just watch compressions, and each tube will be carefully evaluated the anesthesiologist manage these “difficult” patients. on arrival at an ED. The funny thing is that many of the patients I was Placing an ET tube with standard eye-to-vocal cord later called on to intubate in the street met one or more visualization during compressions, in a moving ambu- of those exclusionary criteria. lance, and in the tight confines and configurations pre- Over time, anesthesiologists have become less willing to sented in helicopters, is a difficult task that’s prompting expose themselves to liability by allowing paramedic stu- hospitals, ground EMS systems and aeromedical pro- dents to intubate patients they were contracted to manage. grams to consider video laryngoscopy. Therefore, many of today’s paramedics never intubated a What started out as a creative training aid by innovators live patient prior to being turned loose to intubate in the like Richard Levitan, MD, allowing students to observe prehospital arena. That’s a frightening thought. the anatomy of patients and the process of intubation Laryngoscopy, as we’ve traditionally known it, is also through video imaging, has evolved. It’s now refined and being re-evaluated and reprioritized in protocols by EMS incorporated into compact video laryngoscopes, such as medical directors. The change comes in light of studies the Verathon® GlideScope® Ranger, which shows you an showing that all paramedics are not equally proficient at image on its screen that’s twice the actual anatomical size. the skill, and because the emphasis in cardiac arrest resus- The clarity and utility of the video laryngoscope are so citation is now more directed at continuous and consistent good that anesthesiologists, ED physicians and flight compressions in the early stages of resuscitation than crews are using them on a regular basis. This trend has airway management by intubation. direct ramifications on the prehospital performance of The increasing number of paramedics deployed on fire intubation because, as in-hospital airway management apparatus and ambulances is also resulting in fewer oppor- processes and equipment changes, so too will prehospital tunities in many EMS systems to place endotracheal processes and equipment. tubes, with some placing only one or two tubes annually. This supplement to JEMS presents the advent of the This is presenting new challenges to medical directors and device and how EMS systems are using the tool so you can service training staff because they must more frequently understand the technology and its potential impact on you review and refresh paramedics on this critical skill. This and your service in the future. also increases service and municipality exposure to liability for misplaced endotracheal tubes by their paramedics. A.J. Heightman, MPA, EMT-P,is the editor-in-chief of JEMS and editorial Further, the current demand on hospitals to report and director for Elsevier Public Safety. He’s a former EMS director and EMS reduce medical errors has a significant ripple effect on operations director and has been a paramedic for 30 years.Contact him at prehospital providers transporting intubated patients [email protected].

4 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES The Golden Hour How Time Shapes Airway Management

BY CHARLIE EISELE, BS, NREMT-P

he never saw the truck. She had just dropped the kids off at school and was hoping to run some errands before she had to be at work. She edged her SEscort out of the school parking lot to make a left turn onto the four-lane, trying to see around the truck parked on the northbound shoulder. She pulled out, and an F-150 impacted the driver’s door on the Escort. The collision was over in micro-seconds, with both vehicles coming to rest in the southbound lane. Start the clock. ‘60 PRECIOUS MINUTES’ The “Golden Hour” was first E D I

described by R Adams Cowley, MD, at . C

the University of Maryland Medical K R 1 A Center in Baltimore. From his per- M sonal experiences and observations in The focus of EMS remains bringing the severely injured trauma patient and physician together post-World War II Europe, and then as quickly as possible. in Baltimore in the 1960s, Dr. Cowley recognized that the sooner trauma patients reached defini- Cowley’s team, the focus of EMS remains bringing the tive care—particularly if they arrived within 60 minutes of severely injured trauma patient and physician together being injured—the better their chance of survival. as quickly as possible. Field hospitals, MASH units and medevac helicopters In this effort, we’ve gone from “load and go” to “stay and in the Korean and Vietnam Wars contributed to increas- play” and back again. The ideal level of street medicine ver- ing survival rates. Improvements in medications, tech- sus scene time remains somewhere in the middle. Time niques and instruments were key to survival, but none of spent on scene changes each year with the advent of new these were of any value if the patient remained separated tools and techniques and the results of valid studies. from the surgeon. Our job in EMS is threefold: 1) get to the patient Over the years, we’ve debated whether the Golden quickly, 2) fix what we can fix and 3) quickly get the patient Hour is actually 60 minutes, but Dr. Cowley’s concept to the right hospital. Anything we can do to compress each remains true. Thirty-eight years after Maryland State of these time periods is good for the patient. We’ve known Police Helicopter 1 picked up its first patient on Falls this in the traumatically injured, and now we use it for Road in Baltimore County and delivered him to Dr. STEMI and stroke patients; more are sure to follow.

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 5 The Golden Hour, continued from page 5

AT 12 MINUTES She was unconscious and unresponsive when the medic unit arrived. Her head slumped to the side and frothy blood came from her mouth with each shallow breath. While Rescue Squad 7 worked to free her, the medics brought her head into neutral alignment and tried to open her airway. With a clenched jaw and obvious facial fractures, both an oropharyngeal airway (OPA) and naso- pharyngeal airway (NPA) were out of the question. Working together, the medics used a bag-valve mask, suction and cricoid pressure to optimize oxygenation and ventilation. LOC: Unconscious; grimace to ster- nal rub with an occasional moan; GCS 6. Airway: Compromised by clenched jaw, poor gag reflex, blood in mouth. Breathing: Respirations shallow and rapid; frothy blood present; breath sounds full on right and slightly diminished on left; crepitus on left. Circulation: Radial pulse strong, regular, rapid; no major external bleeding S E Y A

noted. Vitals: HR 144, RR 42, BP 112/62, M

Y E

SaO2 85%. R F F E J IT’S ABOUT PERFUSION The video monitor is placed where you can easily see the screen.The clear image is I used to use the term “airway manage- twice as large as the view afforded by direct visualization and allows for confident and quick landmark identification. ment,” but the words seem to imply our job is done when we successfully get air through the glottis and into the lungs. I tried “respira- PREHOSPITAL INTUBATION— tory management.” Yes, that’s it; secure an air passage, A GOOD THING, SOMETIMES inflate and deflate the lungs. No, that’s not it either. We’ve all read and heard that paramedics shouldn’t intu- I’ve settled, for now at least, on “perfusion manage- bate: “It’s a skill better left for those in the hospital.” But ment.” Our lifesaving job is to return and maintain our field intubation is a good thing. It secures our patient’s patient’s cellular perfusion, and then get them promptly airway. It allows us to properly oxygenate and ventilate to the right facility. patients. It’s usually completed swiftly and appropriately. How are the Golden Hour and perfusion manage- But field intubation can be a bad thing. When we make ment related? Without prudent management of both, poor decisions and fail to execute the skills we were taught, we fail our patient. Almost every lifesaving intervention we extend scene time and create hypoxic patients. When we perform has to do with establishing or maintaining we fail to give post-intubation management the proper cellular perfusion. An AED allows the heart to return attention, it leads to unrecognized misplaced tubes, inap- to a perfusing rhythm. Allowing the hypotensive propriate ventilation and poor oxygenation. patient to breathe on their own instead of paralyzing We intubate patients in the prehospital environment for them encourages blood return to central circulation. three primary reasons: 1) establish and maintain an airway, Decompressing the chest, stopping bleeding, capturing 2) normalize oxygenation, and 3) establish appropriate the airway and ventilating patients with poor oxygen ventilation.2 Although field intubation can be a good thing saturation all improves perfusion. for the patient, it’s not always the right thing for them. So, in the field, the burden of responsibility is on us. So, when do you intubate the patient? When it will make With the critically sick or injured patient, we must look them better or keep them from getting worse. Do you intu- at on-scene interventions with a cynical eye. Does the bate at the scene or during transport? Both. We should procedure enhance perfusion? Must it be done now? intubate when it’s most appropriate. Consider these factors:

6 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES , How sick is your patient? Is the airway patent? What is becoming a tough decision. Tough, until the senior their level of oxygen saturation? Are they ade- paramedic on scene was able to get an 18 gauge IV in quately ventilated? Will they survive transport the patient’s hand; holding it securely as lidocaine, eto- without intubation? midate and succinylcholine were pushed. , What’s your transport time? If scene time exceeds trans- The intubation was performed using a GlideScope® port time, will the intubation make a difference? Is Ranger video laryngoscope, with a clear view on first

good BLS and rapid transport a better option? attempt. Her sats rose to 98% and EtCO2 to 35. She , What’s your intubation skill and experience? Do you have was secured to the board and loaded in the aircraft. As the resources and skills necessary? How are you the succinylcholine wore off, the two helicopter para- making decisions—with your head or your ego? medics assisted her ventilations enough to maintain If you get the patient to the hospital bagging them to sats high sats, but didn’t over-ventilate her and drive blood of 96% with an OPA in place and no gastric inflation, from her central circulation. you’re my perfusion management hero. Ditto if you do it with an ET tube. But if you spend 20 minutes on scene, NOW VERSUS NEXT rooting and digging in a patient’s throat, making multiple I’m a dinosaur. I look at new technology with a suspicious intubation attempts and letting their sats drop to 85%, eye. I see no reason to change for the sake of change. For we need to have a talk. “Do what’s best for the patient,” instance, I finally purchased a PDA cell phone recently, says Maryland State Aeromedical Director Douglas and I realized what everyone seems to have known for Floccare, MD, “and you can’t go wrong.”2 years—they’re amazing. What if it’s a difficult tube? Some of my colleagues The first time I saw a video laryngoscope, I felt much the say that the difficult intubation is the typical intubation, same way I initially did about the PDA: That’s a lot of money and an easy intubation is a gift. They’re right. Anything for a camera and some lights. I also thought, I’ve done just fine that precludes our ability to see the cords or pass the with my bent metal stick for the past two decades, why should I tube has been broadly defined as a “difficult laryn- change now? However, having used the device, I know why. goscopy” or “difficult intubation.”3 Because it’s a better way to deliver patient care, with less Studies on the frequency of opportunity for physical trauma difficult intubations are almost For video laryngoscopy to the patient, quicker visualiza- completely limited to operating to truly enter the world tion of the glottis and enhanced room (OR) or intensive care verification of endotracheal unit (ICU) patients. The num- of prehospital tube placement. ber of studies regarding EMS medicine, a paradigm Straight or curved direct and ED intubations pales shift must occur— laryngoscopy blades are de- drastically in comparison. signed to move the anatomy to Those that have been done a shift away from obtain a line-of-sight glottic focus primarily on the rate of direct visualization. view. Head-neck manipula- undetected esophageal intubation, tongue displacement, tions received at EDs and complications associated with direct contact with laryngeal structures, and impacting intubations done outside the OR. teeth are all opportunities to injure a patient. Until we have studies that focus on difficult intubations Unlike classic laryngoscope blades, video laryngo- in the prehospital arena, we have to rely on these OR and scope blades are shaped to match the pharyngeal anatomy. ICU reports. Do the results of these studies reveal poor The acute blade angle allows the blade’s tip (and camera) intubation technique or poor post-intubation manage- to follow the patient’s anatomy to view the glottis. ment? Are poor intubation outcomes the result of train- Multiple studies have found that 20–40 lbs. of force is ing, technique, tools, experience or conditions? And do required during direct laryngoscopy, and it takes about these factors negatively affect the time to definitive care? 45 lbs. of pressure to fracture a tooth during laryngoscopy.4,5 My own, purely subjective, experience with AT 32 MINUTES video laryngoscopy is that much less force is needed to The helicopter landed as the patient was freed from the obtain a glottic view. I’d like to see studies that validate car and moved to the medic unit. It was a 42-minute drive or dispute my experience. to the only hospital in the county or an 18-minute flight If you’ve ever had to do a belly flop on the ground to to the trauma center. Seemed like an easy choice, but she see the cords of a patient, you’ll appreciate video laryn- was now incredibly combative, so much so that the crew goscopy. The blade goes in the patient’s mouth and the could hardly secure her to the backboard let alone safely video monitor is placed where you can see it. This makes fly her out. visualization easier in a moving ambulance or helicopter, As the minutes ticked away, the easy choice was and has the potential to save scene time by allowing you

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 7 The Golden Hour, continued from page 7

anesthesiologist and assistant professor of trauma anesthesiology at the R Adams Cowley Shock Trauma Center, describes how it worked in his department: “There used to be two camps when direct laryngoscopy failed: the Bullard (rigid fiber-optic laryngoscope) and the LMA (laryngeal mask airway). Now there’s pretty much one camp—video laryngoscopy.” Boehm adds that when video laryngoscopy first appeared as an anesthesia tool in his department, “that camera thing” was used when all other means failed. He and his colleagues now routinely use their GlideScope units as first-line tools, not just as a backup.6 As video laryngoscopy continues to evolve, I’d like to see the ability to digitally record images for QA, patient records and education. I’d like to see the camera and light in a standalone handle, and the image beamed to the multi-function display on our vital signs monitor. Better yet, maybe we could have it recorded on our monitor and also transmitted to the heads-up display on our safety glasses, so we can view the glottis and simultaneously see the patient’s heart rate and oxygen saturation. We live at an incredibly exciting time in history, especially in medicine. Da Vinci robotic surgery, STEMI intervention, laparoscopic surgery and a multitude of N A

M other tools and procedures are developed each week. L L E

E Video laryngoscopy is one of them. It’s a great tool for us N E L

G in medicine, and it’s an important tool for our patients. As new tools and techniques are introduced into the field,and the results Although I’m not ready to put my 4 Mac or 3 Miller on of valid studies support them,we can expect our on-scene times to be eBay, I can’t wait to see what awaits us. positively affected,especially in terms of airway management. Charlie Eisele, BS, NREMT-P,is a flight operations supervisor and flight to intubate easier during transport. The image on the paramedic for the Maryland State Police,Aviation Command. He has been monitor is larger than the view afforded by direct visuali- an EMS and technical rescue instructor for more than 25 years. He’s co- zation. The clear detail provided on the screen allows for developer of the Advanced Airway Program offered each year at EMS confident and quick landmark identification. Today.Contact him at [email protected]. So, what’s the role of video laryngoscopy in prehospital Disclosure:The author has received no monetary support from Verathon medicine? Time for my predictions. It will become the Inc.He has received support from Verathon in the form of a video laryngo- standard of care, just like AEDs and 12-lead monitors. scope for evaluation and research purposes. When our EMS children visit us in nursing homes, we’ll tell them tales of wasting precious minutes lying on the REFERENCES floor of someone’s home, using a light bulb and a metal 1. Franklin F,Doelp A: Shock-Trauma. St. Martin’s Press: New York City, N.Y., 1980. stick to intubate patients. 2. Douglas Floccare, MD, Maryland State Aeromedical Director. Personal communication, 2004–2008. AT 65 MINUTES 3. American Society of Anesthesiologists Task Force on Management of the Difficult The aircraft settled onto the roof, and its rotors slowed Airway:“Practice guidelines for management of the difficult airway: An updated to flight idle. She was moved to the waiting stretcher report by the American Society of Anesthesiologists Task Force on Management and then down the elevator to the trauma room. of the Difficult Airway.”Anesthesiology. 98(5):1269–1277, 2003. Masked, gowned and gloved, the trauma team swarmed 4. Givol N, Gershtansky Y, Halamish-Shani T, et al:“Perianesthetic dental injuries: around her—65 minutes from impact to surgeon. Analysis of incident reports.” Journal of Clinical Anesthesia. 16(3):173–176, 2004. CONCLUSION 5. Ghabash MB, Matta MS, Mehanna CB:“Prevention of dental trauma during endo- For video laryngoscopy to truly enter the world of prehos- tracheal intubation.”Anesthesia and Analgesia. 84(1):230–231, 1997. pital medicine, a paradigm shift must occur—a shift away 6. Clifford Boehm, MD, Assistant Professor of Trauma Anesthesiology, R Adams from direct visualization. Cliff Boehm, MD, an attending Cowley Shock Trauma Center. Personal communication, 2008.

8 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES The Video Laryngoscopy Movement Can-Do Technology at Work

BY JOHN ALLEN PACEY, MD, FRCSC

n 1829, the first known device for Initial advocates of video direct laryngoscopy was invented by laryngoscopy were anes- British physician Benjamin Guy GlideScope® thesiologists in Vancouver, Babington. Later, the work of the Ranger Canada, who performed widely recognized father of laryn- intubations daily. Such luminar- gology, Manuel Garcia, led to the ies as Richard Cooper, BSc, MSc, Ifirst mirror laryngoscope prior to 1849, with a light source MD, FRCPC; John Doyle, MD, PhD; and Ron Walls, later introduced by Alfred Kirstein in 1895.1 MD, raised questions about the viability of direct laryn- In the century since then, the devices available to view goscopy compared with video laryngoscopy and spon- the larynx have gone through many evolutions. Most sored the adoption of the technology in other areas of the devices have been difficult to use, and injuries related to hospital, such as the emergency department (ED) and the failed or delayed tracheal intubation have resulted. ICU. While recognizing the expense of adding the video Recognizing that optimal airway management involves the component, Cooper in particular has commented that direct visualization of the airway during intubation, modern video laryngoscopes are “more robust and resistant to direct laryngoscopy has produced different blade lengths, damage.”2 Adoption in EDs and ICUs has been rapid, and prisms and fiber-optic light channels. However, the emer- it seemed only a matter of time until video laryngoscopy gence of video capabilities in the surgical suite was perhaps was introduced into prehospital medicine. the most significant step in laryngoscopy development. Video laryngoscopy systems provide a clear picture of THE NEED IN THE FIELD the larynx and vocal cords on a display monitor, The literature shows that intubation performed in an enabling control of the endotracheal tube (ETT) in its out-of-hospital emergency environment carries with it a trajectory toward the airway. This type of clearly dis- higher rate of complications and death.3 Rapid sequence played view facilitates fast, accurate ETT placement in intubation (RSI), called for by Rosen and others, initially difficult airways, preventing complications resulting appeared to be effective when coupled with direct from improper tube placement. laryngoscopy (97% in some reports).4 But optimism Other advantages of video laryngoscopy compared with dissipated when a 2003 San Diego study reported that older, fiber-optic systems are substantial. Video images are 45% of “easy” or successful intubations carried out on easily stored on servers and low-cost SD cards, and can be head-injured patients were associated with hypoxemia transmitted to other users, allowing for remote recording or bradycardia.5 of activity, skills coaching and quality assurance reviews. In pediatric patients, the literature shows a need for L A C The use of Internet display is easy either with real-time improved methods. A 2000 San Diego study of 305 pedi- I D E M

transmission or by display of the captured images, so that atric patients showed a success rate of 57%, esophageal N the captured sequences can be used for teaching purposes intubation of 2% and displaced ETT of 15%.6 An older O H T A

to improve the skills of many. As HDTV technology study, from 1989, reported a 50% success rate in children R E V 7 improves, so will the image quality of video laryngoscopy. one year in age or younger. Y S E

Last, video laryngoscopic techniques are easier to master The reasons for these failure rates are obvious to anyone T R U than those necessary for direct laryngoscopy, an important who has worked in the field: the variable intubation skill O C

O factor in its successful use by personnel working in less- levels among EMS personnel and adverse conditions, such T O H than-optimal circumstances. as weather, limited lighting, foreign bodies in the airway P

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 9 The Video Laryngoscopy Movement, continued from page 9

and trauma (leading to hemorrhage and distorted anato- a need for difficult airway management in the trauma set- my). Because direct laryngoscopy in these conditions con- ting. A growing amount of evidence supports the view that tinues to be fraught with difficulty, EMS medical directors video laryngoscopy will be a standard in that setting, but are reconsidering their airway management protocols. more studies are needed before it’s an established reality. Although it’s clear some EMS personnel are able to over- As for speculation about the future of video laryn- come the deficiencies of direct laryngoscopy and produce goscopy in the prehospital setting, aeromedical studies acceptable results, the failure rates have provoked ques- will likely continue to demonstrate the efficacy of RSI tions of whether direct laryngoscopy has become a “legacy using video laryngoscopy. It’s felt that “time on the technique,” introduced when there were no alternatives.8 ground” can be significantly reduced by the use of video laryngoscopy-assisted RSI, either pre-flight or in-flight. GLIDESCOPE IN USE Also, many feel RSI coupled with video laryngoscopy will In 2001, the GlideScope® was introduced as the first com- be shown as the most effective strategy for prehospital mercially available video laryngoscope. The device was intubation management, which will likely involve devel- designed with the recognition that a camera positioned opment of supraglottic airway technology. away from the tip of the device would provide the best The cost of failed or difficult intubation can be very perspective and enhance visualization. The 60º angle high as reflected in a private settlement in excess of $15 allows for 99% Grade 1 and 2 views.2 Another significant million in 2002.9 There’s also the cost associated with design feature is the device’s unique anti-fog component, emotional burden to the providers involved, who may face which reduces lens contamination. insurmountable obstacles to care. The GlideScope Ranger single-use laryngoscope— The added value of video recording will allow medical designed to eliminate the need for disinfecting the blade directors to more accurately measure personnel compe- for fast-paced intubation settings—is being used in Iraq tency and skill success rates, document the depth of ETT and Afghanistan. The backpack-sized, rugged and shock- insertion and enhance education. Overall, these devices proof version of the original device with an antiglare can aid emergency airway management and likely lead to screen was trialed at the R. Adams Cowley Shock Trauma better patient care—a universal goal of all EMS providers. Center, Fort Sam Houston and Andrews Air Force Base. Following successful trials of the device at these world- John Allen Pacey, MD, FRCSc, has been vascular and general surgeon renowned medical facilities, the Ranger was deployed in since 1974 and actively practiced until January 2008.He is a fellow of the hospitals and combat settings. Royal College of Surgeons of Canada and an honorary professor of In particular, a number of reports from the Canadian the Anesthesiology, Pharmacology & Therapeutics Department at the Expeditionary Hospital in Kandahar, Afghanistan, involve University of British Columbia. the management of bloody airways, intubation around Disclosure:The author is the inventor of the GlideScope, and president expanding hematomas and other challenging ETT and research director for Verathon Medical Canada, the makers of exchanges. The Ranger is also in trials with Whatcom GlideScope systems. County (Wash.) EMS, where the early results are encouraging, according to Medical Director Marvin Wayne, MD. REFERENCES Aeromedical applications, notably in helicopter envi- 1. Proceedings of the Royal Society of London. vii:399–410, 1856. ronments, are also under study with the GlideScope 2. Cooper RM, Pacey JA, Bishop MJ, et al:“Early clinical experience with a new video Ranger. It’s notable that first-time aeromedical users had laryngoscope (GlideScope) in 728 patients.” Canadian Journal of Anaesthesia. a high success rate even in the most adverse conditions. 52(2):191–198, 2005. Reports of Ranger intubation under unusual conditions 3. Murray JA, Demetriades D, Berne TV, et al:“Prehospital intubation in patients with include two intubations prior to extrication from crushed severe head injury.”Journal of Trauma. 49(6):1065–1070. vehicles, in flight re-intubation, and in-flight primary 4. Bulger EM, Copass MK, Maier RV, et al:“An analysis of advanced prehospital airway intubation (where direct laryngoscope use is limited). management.”Journal of Emergency Medicine. 23(2):183–189, 2002. 5. Dunford JV, Davis DP,Ochs M, et al:“Incidence of transient hypoxia and pulse rate A LOOK FORWARD reactivity during paramedic rapid sequence intubation.” Annals of Emergency There’s considerable pressure on EMS to improve success- Medicine. 42(6):721–728, 2003. ful intubation rates, and the advent of video laryngoscopy 6. Gausche M, Lewis RJ, Stratton SJ, et al:“Effect of out-of-hospital pediatric endotra- designed for the field is poised to produce findings that cheal intubation on survival and neurological outcome: A controlled clinical trial.” support its use in this demanding context. How extensive a JAMA. 283(6):783–790, 2000. role this technology will play is complicated by the debate 7. Aijian P,Tsai A, Knopp R, et al:“Endotracheal intubation of pediatric patients by para- over whether intubation—considered the gold standard in medics.”Annals of Emergency Medicine. 18(5):489–494, 1989. anesthesia practice—is necessary for all compromised air- 8. Cooper RM:“Is direct laryngoscopy obsolete?”Internet Journal of Airway Management. ways. EMS personnel work with patients who are often Vol. 4, 2006–2007. www.adair.at/ijam/volume04/specialcomment01/default.htm treated under adverse conditions, and there will always be 9. Law Offices of Wade E. Byrd, P.A.232 Person St. Fayetteville, NC 28301.

10 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES ‘Grounded’Care Use of Video Laryngoscopy in a Ground EMS System: Better for You, Better for Your Patients

BY MARVIN WAYNE, MD, FACEP, FAAEM

irway manage- THE ADVENT OF VIDEO ment is a basic LARYNGOSCOPY and essential skill For many years, direct laryn- of anyone caring goscopy (DL) has been the gold for an injured or standard by which to achieve a seriously ill intubation, performed with patient.A Although many patients either curved or straight laryn- can be managed with a non- goscope blades. However, DL invasive airway, many benefit from often yields surprisingly poor endotracheal intubation. laryngeal views. Alternatives Much has been written about have been explored, but most the hazards of endotracheal intu- have proved to be difficult to bation, even in this latter patient master, time consuming, unreli- group. Paralytics have been sug- able and costly. Even rigid gested, and utilized, by some The Ranger was used in 18 seconds to visualize this fiber-optic laryngoscopes—the ground and air EMS systems, but patient’s airway, which was affected by airway burns. technology on which “modern” concern has arisen over the ability DL is based—hasn’t been widely of crews to achieve effective intubation even with paralytics. used, despite its advantages. What has been needed is a One study, for example, showed esophageal intubation device that provides a full view of the glottic airway dur- rates for all patients as high as 25%.1 The challenge for ing laryngoscopy and is easy to learn and master by prehospital advanced life support (ALS) providers, then, is medical personnel who may or may not frequently per- achieving a balance between the need for intubation and form intubations. safely achieving that intubation. A significant advance took place in this realm when the Even in the most controlled circumstances, endotra- video laryngoscope (VL) was developed for use in the sur- cheal intubation can be challenging. Although the addition gical suite. These devices have a camera lens incorporated of routine end-tidal CO2 (EtCO2) monitoring has reduced into the handle or blade, allowing the image of the larynx/ the incidence of esophageal intubation, it does not reduce glottis to be displayed on a monitor that’s either directly the difficulty of the prehospital intubation process. In the attached to, or separate from, the blade/camera system. field, poor lighting conditions, bad weather, the physical The ability to see the larynx while intubating, even in the location of the patient, injuries to the neck and spine, and most difficult patients, as well as being able to use the variations in skill levels of the operators contribute to that monitor as a teaching tool, are recognized as important difficulty. But new technology may be able to provide advancements in airway management. some, if not all, of the solution to that dichotomy.2 Although many of these devices (i.e., McGrath Series 5 The goal of any new airway technology should be to from LMA North America, TruView from Truphatek, reduce multiple attempts at intubation, as well as prevent Storz DCI, AWS-S100 from PENTAX Medical Co., dental, mouth and airway trauma, desaturation, intracra- Video Macintosh Intubating Laryngoscope System from nial hypertension, pneumothorax, pulmonary aspiration Volpi AG and GlideScope® from Verathon Medical®) have and even iatrogenic death from an unrecognized proved their worth in the hospital setting, a new design esophageal placement.2 was necessary for use in the prehospital environment.

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 11 ‘Grounded’ Care, continued from page 11

This new device would have to be rugged, small and easy the camera is directed (by design) at a 60º angle. to manipulate when working in difficult field conditions. The manufacturer recommends bending the ET tube Currently, the only product on the market that we believe to conform to the shape of the blade for a gentle curve of meets all of the criteria for use in the prehospital environ- 60º. Still, the angle by which one inserts the tube is quite ment is the compact GlideScope Ranger. steep. A special stylet developed to lessen the difficulty of The Ranger has a digital camera lens incorporated into passing the tube into the trachea is available, but if advanc- the center (versus the tip) of its specialized blade, which ing the tube presents a problem, withdrawing the allows a wider view of the vocal cords on its monitor. A GlideScope 1–2 cm will allow the larynx to drop down and unique anti-fogging technology provides an unobstructed reduce the angle required to insert it correctly. view of the larynx throughout the entire process of tube The main limitation of the GlideScope is that there placement, a feature that’s especially valuable during emer- may be a physical resistance in the advancement of the gency intubation. It weighs less than ET tube; with a little practice this 2 lbs. and is engineered to be limitation is easily overcome. But dependable in a variety of challeng- once familiar with the steep angle of ing field conditions, including very approach, the device is extremely high or low temperatures, high easy to handle. humidity, and high altitude. The Ranger is powered by a CASE REPORTS rechargeable lithium battery, which The following are examples from provides a minimum of 90 minutes Whatcom (Wash.) Medic One of the of continuous use. A rigid stylet aids type of cases in which the GlideScope in the control of the endotracheal Ranger may be extremely useful. tube (ETT) as it enters the larynx. This image on the Ranger’s color display shows Case 1: EMS responded to a con- The blade has a 60º curvature in the the airway of an actual overdose patient. scious 57-year-old female, a victim of midline to match anatomical align- a fire that started in her home. She ment, so it doesn’t require a “line of sight” for a good view. had second-degree burns on her legs, buttocks and thighs The high-resolution color display monitor provides a clear greater than 30% of her body. She had redness of her face, picture of the larynx and vocal cords even in bright light, but no obvious singeing of nares. There were questionable which, again, transforms it into a valuable teaching tool. particulates in her oral cavity, but no voice change. Pulse There appear to be special benefits to the GlideScope oximetry was 93% on room air, rising to 95% on oxygen Ranger for trauma patients with limited mouth opening given by non-rebreather (NRB) mask. The patient had a or in cervical immobilization.3 Very little force is required history of smoking one pack per day. Respiratory rate was to expose the glottic opening with the blade so manipula- 30 but appeared unlabored. Blood pressure was 130/90, tion of the head and neck is reduced. It also functions well heart rate was 110. She was awake and talking. in situations where blood or other fluids are present, in Because she was 25 miles from a community hospital and mildly obese patients, and because direct visualization 100 miles from a burn center, and although a major airway of the glottis is unnecessary during intubation, the burn was not expected, it was elected to provide rapid GlideScope Ranger is less stimulating, an advantage for sequence intubation (RSI) as a precaution prior to helicop- use in semi-awake patients. ter transport to the burn center. RSI was conducted, and the GlideScope Ranger was used to visualize the airway. A NEW TECHNIQUE Surprisingly, the crew found she had soot in her pyriform The manner in which tracheal intubation is performed with sinuses, edema of her glottic opening and significant ery- the GlideScope is unique to its design. The handle is held thema of the entire region. The GlideScope made possible in the left hand in the same way that one would hold a stan- a quick (18 seconds) and easy intubation, and the video dard laryngoscope, while the blade is inserted between the monitor provided an excellent teaching opportunity the teeth under direct vision. It’s important to start out in the prehospital personnel involved. In addition to direct visual- midline of the tongue and to stay on the midline. (There’s ization, EtCO2 further confirmed correct tube placement. no need to sweep the tongue out of the way, as is usually the Case 2: EMS responded to a 60-year-old male in severe practice with conventional laryngoscopes.) respiratory distress. He was in the bedroom of a manufac- When the uniquely curved blade passes the teeth, the tured home. He suffered from severe Pickwickian syn- clinician can now follow the landmarks on the video mon- drome related to morbid obesity, and had a body mass itor proceed to the larynx. Identifying the glottis is gener- index (BMI) of 43. (His weight was approximately 656 lbs). ally easy. The only technical difficulty with the GlideScope He was obtundent and had a pulse ox of 85%. Blood may be guiding the ETT toward the image of the glottis pressure could not be obtained in the patient’s current seen on the screen. This difficulty is encountered because position, and moving the patient would require assistance

12 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES that was not available at the time. His respiratory rate was air medical personnel who must work in tight quarters 40, shallow and labored. Oxygen by NRB mask did not while airborne. improve his condition. As previously mentioned, field intubations are by defi- In light of further deterioration, intubation was the only nition fraught with potential complications, such as alternative. However, his BMI and body habitus were esophageal intubation, pneumothorax, reduced ventila- going to make it a difficult intubation. He was sedated with tion and oxygenation, and pulmonary aspiration.2 midazolam and, using the Ranger, was intubated within 26 Because of the ability to visualize the airway without dis- seconds. Despite limited mouth opening and a difficult tortion from fogging to, in effect, “see around the cor- position, tube passage was assured via excellent visualiza- ner,” many of these complications can be avoided. tion of his vocal chords. One study looked at Cormack-Lehane ratings (Grades Case 3: EMS responded to a 67-year-old male in car- 1–1V) of those obtained with the GlideScope in 15 diac arrest found in an alley behind a tavern. It was 2 a.m. patients with cervical collars.4 The Cormack grading in 14 and raining, and he was difficult to get to because vehicle of the 15 patients (93%) was reduced by one when using access was blocked by construction in the area. The first the GlideScope. Five Grade I1 patients became Grade 1 responding basic life support (BLS) unit started CPR using the GlideScope. The average time of intubation with bag-mask ventilation (BMV) performed with with the GlideScope was 38 seconds without complica- extreme difficulty. tions, including any damage to the teeth. This improve- The patient had vomited copious amounts of stomach ment in visualization of the glottis during intubation is a contents. The AED showed that no shock was indicated. major factor in the conclusion of some that direct laryn- After suctioning the oral cavity, intubation was performed goscopy for emergency intubation will become a relic.2,3 with the Ranger in 33 seconds. Tube placement was con- The GlideScope has also become the method of firmed by direct visualization on the GlideScope monitor choice for many in training of airway management.5 and EtCO2. The patient, who had probably sustained a Currently, Whatcom Medic One is conducting a primary respiratory arrest, was successfully resuscitated. crossover study of video camera-assisted intubation ver- Case 4: EMS responded to a car struck by a semitruck at sus traditional laryngoscopy. Although preliminary data high speed. The driver of the car was trapped in the vehicle is encouraging, many questions remain to be answered. and had significant craniofacial trauma. His airway was These include cost versus benefit and skill maintenance compromised, and he had agonal respiration. To extricate of the traditional technique when a camera system isn’t him, extensive rescue operations were required. available. Time and the marketplace, we believe, will help A paramedic was able to intubate the patient from the answer those questions. However, a new era of airway open windshield using a Ranger with the blade of the laryn- management may soon be on all of our horizons. goscope reversed. It took two attempts and 42 seconds to place the tube, with suctioning required after the first Marvin Wayne, MD, FACEP, FAAEM, is an associate clinical professor attempt. Confirmation of tube placement was done via at the University of Washington, the EMS medical director for direct visualization on the GlideScope monitor and EtCO2. Bellingham/Whatcom County, Wash., and an attending physician in the These case reports demonstrate the capabilities of a emergency department at St. Joseph Hospital, Bellingham,Wash. video laryngoscope, now available to EMS personnel, in Disclosure: The author has received no monetary support from performing emergency intubation. In the first case, without Verathon Inc. His EMS system, Bellingham/Whatcom County, Wash., has video visualization it would have been difficult to diagnose received support from Verathon in the form of four video laryngoscopes the glottic swelling that was unsuspected on initial exami- for evaluation and research purposes. nation. In the second case, this high-BMI patient with complex anatomy might not have been able to have any airway REFERENCES achieved. In the third, a dark night, aspiration and other 1. Katz SJ,Falk JL:“Misplaced endotracheal tubes by paramedics in an urban emergency factors made any airway extremely difficult. And in the medical services system.”Annals of Emergency Medicine. 37(1):32–37, 2001. fourth, it’s unlikely the intubation could have taken place at 2. Rao BK, Singh VK, Ray Sumit, et al:“Airway management in trauma.”Indian Journal all until the patient was extricated from the vehicle. of Critical Care Medicine. 8(2): 98–105, 2004. The ability to successfully intubate critical patients in the 3. Rose DK, Cohen MM:“The airway: Problems and predictions in 18,500 patients.” field, especially those who present with difficult airways for Canadian Journal of Anaesthesia. 41(5 pt 1):372–383, 1994. a variety of reasons, is an important advancement in emer- 4. Sakles J:“The GlideScope Video Laryngoscope:A practical guide to the future of air- gency airway management. way management.”Emergency Medicine and Critical Care Review.2(1):34–35,2006. 5. Agrò F, Barzoi G, Montecchia F:“Tracheal intubation using a Macintosh laryngo- THE IMPACT ON PREHOSPITAL CARE scope or a GlideScope in 15 patients with cervical spine immobilization.” British The potential impact of video laryngoscopy on prehos- Journal of Anaesthesia. 90(5):705–706, 2003. pital medicine may be significant, especially for ground 6. Rai MR,Dering A,Verghese C:“The GlideScope system:A clinical assessment of per- services that are often faced with difficult airways and formance.”Anaesthesia 60(1):60–64, 2005.

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 13 Up in the Air Video Laryngoscopy Holds Promise for In-Flight Intubation

BY LARS P. BJOERNSEN, MD,& M. BRUCE LINDSAY, MD

n the prehospital goscopy.5 In addition, setting, emergen- conventional laryngoscopy cy care providers routinely causes move- must anticipate dif- ment of the unprotected ficult airways. Air cervical spine.6 medical crews in The prehospital setting E D I

particular are routinely . itself, particularly in lim- C K

I R tasked with managing the A ited workspaces (like that M most difficult airways— Intubation takes about twice as long in-flight due to the confined space, of a helicopter), further those complicated by con- calling for a quick and reliable means to intubate while in the air. increases the difficulty of comitant head injuries, intubation. And yet, a 1998 multisystem trauma or presumed cervical spine injury. study showed that air medical intubations, both pre-flight Ideally, an airway should be efficiently secured with the and en route, for scene calls and interhospital transports, method that offers the greatest safety and the least morbid- are accomplished with a very high success rate.7 ity. The standard advanced prehospital method in trauma However, in-flight intubation takes approximately twice patients has been rapid sequence induction (RSI) oral intu- as long as intubation in a ground setting. This prolonga- bation with direct laryngoscopy, which has been shown to tion of intubation is primarily due to problems with posi- be a safe air medical practice.1 tioning of the air medical crew and patient.8 Because a In-flight airway management decision-making and greater success rate is reported when intubation is per- practice are significantly influenced by practice setting formed before takeoff, there have been many documented and aircraft type, but the success rate of intubation in the cases in which the crew decided to perform an emergency air medical service is equal to the prehospital setting over- landing and RSI rather than attempt in-flight intubation.9 all, with air medical personnel routinely contributing to the prehospital care of injured patients by establishing PROMISING NEW TECHNOLOGY definitive airways.2 We believe innovative technologies, Studies have proven the video laryngoscope as an effective such as video laryngoscopy, will improve the success rates device for tracheal intubation and shown it provides an and decrease the morbidity of prehospital intubation, as it improved view of the vocal cords compared with tradi- is in our aeromedical practice at the University of tional laryngoscopy, even in difficult intubations.10 Wisconsin Hospitals and Clinics. Although not yet extensively tested in the prehospital setting, case reports show that the video laryngoscope is a IN-FLIGHT CHALLENGES promising device for emergency intubation, leading experts Difficult intubation is encountered in approximately to predict that video laryngoscopy will dominate the field 7–10% of patients requiring prehospital emergency endo- of emergency airway management in the future.11 tracheal intubation.3 Stabilization of the cervical spine The goal of the video laryngoscope is to facilitate the makes it more difficult to visualize the vocal cords using visualization and recognition of anatomical structures and conventional direct laryngoscopy because optimal align- to facilitate manipulation of airway devices. With its low ment of the airway axis requires neck extension.4 Further, weight, high-resolution screen and compact size, the cervical collars significantly reduce the ability to open a portable video laryngoscope has the potential to be a useful patient’s mouth, contributing to poor views on direct laryn- device for air medical crews.

14 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES Additionally, it provides significant benefit in situa- video laryngoscopy and direct laryngoscopy by ground tions where access to the patient’s head is limited, such EMS or air medical crews. One randomized, single- as during automobile extrication or in air medical set- blinded study that compares different types of video tings when the intubator may be placed adjacent to the laryngoscopes and traditional direct laryngoscopy with patient instead of in line with the patient’s head. The Macintosh laryngoscope was recently started.15 This intubator is not required to be “in line” with the patient study will hopefully provide guidance toward implemen- and therefore can be easily applied in-flight and in other tation of a video laryngoscope for prehospital difficult settings with limited space.12 airway management.

CASE REPORT Lars P.Bjoernsen, MD, is an emergency medicine resident physician at No scientific studies have yet looked at intubation success the University of Wisconsin Hospitals and Clinics. He was an EMT- rates in the air medical setting with video laryngoscopy or intermediate in Oslo,Norway.Contact him at [email protected]. evaluated the benefit of intubation in-flight with video ver- M. Bruce Lindsay, MD, is a flight physician and medical director of UW sus direct laryngoscopy on the ground. Until those studies Med Flight and an associate professor in the Section of Emergency have been conducted, we must look to case studies for anec- Medicine at the University of Wisconsin School of Medicine and Public dotal reports of this device’s impact on prehospital airway Health.Contact him at [email protected]. management, including a case report we have submitted to Disclosure:The authors have reported no conflicts of interest. a peer-reviewed journal.13 Our air medical service was called to the scene of a REFERENCES high-speed motor vehicle crash, where the flight crew 1.Vilke GM, Hoyt DB, Epperson M:“Intubation techniques in the helicopter.” Journal of intubated a 26-year-old male driver pre-flight (in the Emergency Medicine.12(2):217–224, 1994. ground ambulance). On first contact with the air medical 2.Thomas SH, Harrison T,Wedel SK:“Flight crew airway management in four settings: a crew, the immobilized patient had a Glasgow Coma Scale six-year review.”Prehospital Emergency Care. 3(4):310–315, 1999. of three, with rapid, snoring respirations, a blood pres- 3.Adnet F,Jouriles NJ, Le Toumelin P,et al:“Survey of out-of-hospital emergency intuba- sure of 106/60 and a heart rate of 118. Because of trauma tions in the French prehospital medical system: A multicenter study.” Annals of to the head and possible cervical spine injuries, it was Emergency Medicine. 32(4):454–460, 1998. anticipated to be a difficult airway case. 4.Hastings RH, Wood PR:“Head extension and laryngeal view during laryngoscopy with While in the ambulance, the air medical crew secured cervical spine stabilization maneuvers.”Anesthesiology.80(4):825–831, 1994. the patient’s airway using RSI and oral-tracheal intubation 5.Heath KJ:“The effect of laryngoscopy of different cervical spine immobilisation tech- with a GlideScope® Ranger video laryngoscope. In-line niques.”Anaesthesia.49(10):843–845, 1994. immobilization of the neck was provided by one of the 6.Hastings RH,Marks JD:“Airway management for trauma patients with potential cervical paramedics and cricothyroid pressure held by the other. spine injuries.”Anesthesia & Analgesia.73(4):471–482, 1991. The GlideScope Ranger video laryngoscope provided an 7.Slater EA, Weiss SJ, Ernst AA, et al:“Preflight versus en route success and complica- excellent, unobstructed view of the vocal cords and an tions of rapid sequence intubation in an air medical service.” Journal of Trauma. endotracheal tube was easily passed. The patient was trans- 45(3):588–592, 1998. ported by helicopter to the regional Level 1 trauma center, 8.Stone CK,Thomas SH:“Is oral endotracheal intubation efficacy impaired in the helicop- where evaluation revealed extensive multisystem injuries. ter environment?”Air Medical Journal. 13(8):319–321, 1994. We have utilized the video laryngoscope for simulated 9.Braude D, Boling S:“Case report of unrecognized akathisia resulting in an emergency patients (manikins) in the patient care compartment of both landing and RSI during air medical transport.” Air Medical of New Mexico. an EC-135 and Agusta 109 Power aircraft. Intubation posi- 25(2):85–87, 2006. tion varied, both from the head of the patient and next to 10.Rai MR, Dering A,Verghese C:“The GlideScope system: a clinical assessment of per- the patient, during daylight and limited light settings. We formance.”Anaesthesia. 60(1):60–64, 2005. found the device easy to use when standard direct laryn- 11.Sakles JC, Rodgers R, Keim SM:“Optical and video laryngoscopes for emergency air- goscopy would have been difficult or impossible. way management.”Internal and Emergency Medicine. 3(2):139–143, 2008. 12.Braude D, Richards M:“Rapid Sequence Airway (RSA):A novel approach to prehospital CONCLUSION airway management.”Prehospital Emergency Care. 11(2):250–252, 2007. No single airway device offers a solution to all scenar- 13.Bjoernsen LP,Parquett B, Lindsay B:“Prehospital use of video laryngoscope by an air ios, but we consider the video laryngoscope a useful medical crew.”Air Medical Journal.In Press (scheduled September/October 2008). addition to the range of devices available to the air med- 14.Henderson J, Popat M, Latto P,et al:“Difficult Airway Society guidelines.”Anaesthesia. ical crew. The use of these devices has been suggested in 59(12): 242–1243; author reply 1247, 2004. recent guidelines as an alternative technique in difficult 15.Samuels J,Brody R:“Comparison study in adult surgical patients of five airway devices.” intubations, and case reports have suggested that it can (Prospective,randomized comparison of intubating conditions with Airtraq Optical,Storz be beneficial when managing a patient with cervical DCI Video,McGRATH Video,GlideScope Video,and Macintosh Laryngoscope in random- immobilization.13-14 ly selected elective adult surgical patients.) Weill Medical College of Cornell University: However, no studies yet compare prehospital use of ClinicalTrials.gov identifier: NCT00602979. (Planned start April 2008.)

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 15 The Military Experience The GlideScope Ranger Improves Visualization in the Combat Setting

BY MICHAEL R. HAWKINS, MS, CRNA

t’s 1800 HRS, and the radio calls for the Trauma reported as many as 70% of laryngoscopies performed Team to report to the emergency department had poor glottic visualization and required multiple laryn- STAT. The information coming across the radio goscopy attempts.1 Even data in the hospital/surgical continues: “Medivac inbound. Two urgent setting shows that clinicians encounter poor glottic surgicals, one intubated. Ten-minute ETA.” visualization in as many as 9% of laryngoscopies.2 Although it may sound like the initial report of In the combat zone, more than 75% of surgical injuries Ian inbound helicopter at any urban trauma center in the presenting to a Combat Support Hospital (CSH, pro- U.S., the reality is that minutes before, the flight medic nounced “CaSH”) result from either improvised explosive rolled out of a Black devices (IEDs) or gun- 1 Hawk helicopter in shot wounds (GSWs).3 Iraq to meet a combat These patients fre- medic who had just quently present with pulled two of his fellow blast or penetrating soldiers out of their fragment (shrapnel) Humvee. Over the roar injuries that disrupt of the helicopter and the integrity of the small arms fire in the oral, pharyngeal or distance, the medic glottic structures. quickly gives a report, These injuries can yelling, “IED. Patient make direct laryn- One was unconscious. I goscopy (DL) even intubated him. Has a more challenging. loose dressing on his Thus, airway manage- neck. Open neck ment and optimal DL wound, right side, success in the combat bleeding controlled. setting require concise Right leg is partially CPT Michael R. Hawkins (left) and COL Thomas C. Broach (right) show their airway protocols and amputated at mid- GlideScope® Rangers at the 325th CSH, COB Speicher, Iraq. experience, as well as thigh, and a tourniquet equipment that’s reli- is in place. Patient Two is awake. Multiple fragment able, sturdy and enhances the provider’s proficiency. wounds on his face, right arm and leg.” The casualties are In addition to the challenges of glottic visualization loaded into the Black Hawk and urgently flown to the during endotracheal intubation (ETI) in the complex nearest Combat Support Hospital. trauma airway, military medics and prehospital providers Whether you’re a prehospital medic in the mountains also face the constant task of minimizing the amount and of Afghanistan or the sands of Iraq, many of the same air- size of equipment necessary to deal with these injuries. way issues that challenge EMS here in the U.S. also chal- With the advancement of technology, several video lenge the prehospital providers in the combat zones of the laryngoscope systems have been developed that enhance Middle East. One North American airway study conducted the view of the glottis with the goal of improving laryn- in a large urban EMS system found that paramedics goscopy success rates in the difficult airway. Verathon

16 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES 2

Medical® has developed the GlideScope® Ranger Video Laryngoscope (Ranger), a compact, sturdy system that can with- stand the demanding operating environment of the military. The blade of the Ranger is similar to a Macintosh blade but has a pronounced 60o angulation and incorporates a high- resolution color camera with the image displayed on a 3.5" LCD panel. Because of the size and durability of the Ranger, it was the ideal video laryngoscope system to test in combat. SENDING THE RANGER ‘DOWN RANGE’ ... TO IRAQ! The GlideScope LCD shows the view of the glottis in this burn patient prior to removal of the An Army anesthesia team deployed to a trach tube placed in the field. CSH in Northern Iraq supplemented the standard “difficult airway” equip- 3 ment with the Ranger (see Photo 1). The use of the Ranger was tracked during a six-month period, and data was collected on how the device functioned. In this study, Army providers utilized the Ranger as the primary “difficult airway” adjunct for any patient requiring ETI with predictive factors that would clas- sify the patient as a difficult intubation.3 Some of the factors included a Mallampati score of two or higher, dis- ruption or penetration of tissue in the neck or oral-pharyngeal region from IED or GSW fragments, facial and airway thermal injuries, or potential cervical spine trauma. Even though the Ranger was utilized exclusively on difficult airway cases, At a combat support hospital, after it was determined that the glottis was patent, providers reported the view seen on the staff performed laryngoscopy with the Ranger and placed an endotracheal tube. LCD screen as equal to a Cormack- Lehane, Grade I view in 97% of patients. A partial view Paramedic/physician providers who had infrequent use (Cormack-Lehane, Grade II) was reported in the remain- of laryngoscopy skills reported that the device enhanced ing 3%. There were no reported cases of obstructed glot- their ability to obtain a glottic view. As a result, these tic view with the Ranger. Data collected from studies in providers reported that the individual confidence level of North America had similar results.4,5 obtaining an ETI in a difficult airway was greater. Despite some combat casualties presenting with dis- And finally, despite the harsh operational environ- rupted oral-pharyngeal tissue or blood in the supraglottic ment of a combat zone, there were no mechanical/ region, the recessed location of the optics in the Ranger’s functional failures seen with the Rangers during the blade allowed the view on the LCD screen to remain study period. unobstructed by blood and tissue. Providers also reported that the required “forward- CASE 1: PENETRATING FRAGMENT lifting” force used by the GVL® blade to obtain a Grade INJURIES/BURN VICTIM I view was generally less than that used with a Macintosh An Iraqi local national was driving a car that was hit by an blade, and significantly less than that required of a Miller IED and caught fire subsequent to the blast. The driver of blade. Providers were also able to intubate their patients the car, injured by both primary and secondary IED with the GVL blade without removing cervical collars. fragments, was pulled from the vehicle by U.S. soldiers

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 17 The Military Experience, continued from page 17

and given initial emergency care. 4 intubated exactly in the position Prior to transport, a field medic found.” Second, “the force required to established a peripheral IV and obtain a glottic view is minimal.” The attempted oral laryngoscopy. Due to goal was to be as gentle as possible. the IED’s blast wave and thermal And finally, “it was felt that the effects, his oral and supraglottic tissue Ranger would give the providers the had swollen over the glottic opening quickest, clearest view of the glottis.” and ETI was unsuccessful. The patient received an emergency CONCLUSION surgical cricothyrotomy and was Video laryngoscopy using the Ranger transported to a CSH where he was has simplified management of the evaluated and taken to the operating difficult airway in the combat envi- room for his initial surgery. After ronment. It has given patient-care approximately 72 hours, the tissue providers a compact and durable swelling of both the patient’s face and This patient presented to a medic in the device to definitively secure ET tubes airway had decreased significantly. field with an unexploded ordinance (UXO) in in complex airways. In addition, it Prior to removing the surgical his leg, which could have been triggered by may be the optimal way to secure the slightest movement.The Ranger was cricothyrotomy, the GlideScope used to perform laryngoscopy and secure an endotracheal tubes in those patients Video Laryngoscope system was uti- endotracheal tube in the exact position the with suspected cervical-spine injuries lized to assess the patency of the patient was found and with minimal force. or traumatized airways. For EMS glottic opening (see Photo 2). systems that struggle to maintain Despite mild swelling and sloughing of airway proficiency with ETI, the GlideScope may level the epithelial tissue above the glottis, it was determined that skill requirement enough to increase the overall success the glottis was patent. The trach tube was safely rates of ETI by providers who have infrequent intuba- removed from the cricothyroid space, and an endotra- tion experience. cheal (ET) tube was then placed from above through his glottic opening (see Photo 3). Michael R.Hawkins,MS,CRNA,(CPT,USAR),is a certified registered nurse anesthetist at Dartmouth-Hitchcock Medical Center,Lebanon,N.H.,and an CASE 2: UNEXPLODED ORDINANCE instructor in Anesthesia at Dartmouth Medical School.He’s also a captain LODGED IN THE LEG with the U.S. Army Reserve, 405th Combat Support Hospital, West A patient presents with an explosive device embedded in Hartford, Conn., and was deployed to Iraq in 2005 and 2007–2008. his leg and any movement could trigger it. This was a Disclosure:The author has received no monetary support from Verathon dilemma faced by the medic of a combat unit in Iraq. His Inc. His EMS system, U.S. Army, 325th CSH, has received support from patient was awake and alert, had no airway distress, and Verathon Inc. in the form of a video laryngoscope for evaluation and minimal bleeding from the entrance wound of the unex- research purposes. ploded ordinance (UXO). Once it was determined that there was no emergent surgical need to control bleeding, The views expressed in this article are those of the author and a plan was carefully devised to remove the UXO from the do not reflect the official policy or position of the Department leg of this patient with minimal movement. of the Army, Department of Defense or the U.S. Government. The area around the patient was cleared and secured. A surgeon and anesthetist responded from the CSH to assist REFERENCES the medic in removing the UXO. The team of three care- 1. Ochs M, Davis D, Hoyt D, et al:“Paramedic-performed rapid sequence intubation fully removed enough clothing to establish an IV line, all of patients with severe head injuries.” Annals of Emergency Medicine. the while cognizant that any movement could trigger the 40(2):159–167, 2002. device. The patient required general anesthesia in order 2. Crosby ET, Cooper RM, Douglas MJ, et al:“The unanticipated difficult airway with to remove the UXO from his leg, and the goal was to per- recommendations for management.” Canadian Journal of Anesthesia. form rapid sequence induction with minimal or no move- 45(8):757–776, 1998. ment. Once the patient had an IV and was placed on oxy- 3. Hawkins M, Broach T: “Clinical report: Video laryngoscopy, utilizing the gen, he was induced with general anesthesia. After the GlideScope Ranger in the combat setting.” Journal of Clinical Anesthesia. patient was asleep, the Ranger was used to perform the Pending publication. laryngoscopy and secure an ET tube. Once the airway was 4. Cooper RM,Pacey JA,Bishop MJ,et al:“Early clinical experience with a new video secured, the surgeon, medic and explosive ordinance team laryngoscope (GlideScope) in 728 patients.” Canadian Journal of Anesthesia. removed the UXO (see Photo 4). 52(2):191–198, 2005. The providers later acknowledged that the Ranger was 5. Rai MR, Dering A,Verghese C:“The GlideScope system:A clinical assessment of utilized for several reasons: First, “the patient could be performance.”Anaesthesia. 60(1):60–64, 2005.

18 THE PERFECT VIEW ELSEVIER PUBLIC SAFETY Using Is Believing Highlights from 72 Cases Involving Video Laryngoscopy at Martin County (Fla.) Fire Rescue

BY DAVID ZARKER, EMT-P

ecently, I attended a within two attempts to 13% after seminar where the more than two attempts, and brady- keynote speaker rec- cardia occurred in only 1.6% of ommended endotra- twice-attempted intubation patients cheal intubation be versus 21% for patients undergoing abandoned as a pre- more attempts. Rhospital skill. A great deal of discussion Our department was on track with ensued, mostly regarding the compli- these complications, and we needed cations and legal liability of failed a solution. intubations and misplaced tubes, as well as the implication of new adjuncts A NEW WAY to replace intubation. In March 2007, several members of Rescue lieutenants, who carry the Ranger in Although I believe we’ve seen great Martin County (Fla.) Fire Rescue, this special response bag, have additional improvements in airway adjuncts in training and are authorized by the medical attended the EMS Today conference, the past several years, they’ve all had director to perform retrograde intubations, where we were introduced to the limitations and complications, and oral intraosseous infusion and RSI. GlideScope® Ranger. I arranged to tracheal intubation has remained the have a representative present the “gold standard” for airway control and maintenance. Thus, Ranger to our department for a more in-depth evaluation. rather than discontinue this life-saving procedure, we A regional sales rep brought a unit to our training office should attempt to figure out why it’s problematic in the pre- and we had several of our rescue lieutenants (EMS supervi- hospital setting and develop ways to improve its success. sors) and paramedics use the unit to intubate our training As an EMS supervisor, part of my job is to administer our mannequins. Intubation with the Ranger is slightly differ- agency’s quality assurance program. Because our depart- ent than what paramedics are used to. So there was a small ment uses rapid sequence induction (RSI), failure to secure learning curve, but after 10–15 minutes of practice, every- an airway isn’t an option, and this intervention is monitored one was comfortable with the equipment and able to intu- closely. In November 2006, my colleagues and I noticed an bate effortlessly. We easily intubated the difficult airway increase in unsuccessful intubations and a series of multiple head and a mannequin with a cervical collar in place. In all intubation attempts. We monitored this for several months cases, we were able to intubate on the first attempt and in to ensure we were seeing an actual trend and not just a “bad an acceptable timeframe. month.” In February 2007, we determined it was a trend, Because it was the middle of our budget year, it took and we set out to resolve the problem. some juggling of funds, but by fall 2007 we were able to Not only is it imperative to secure an airway, it must be purchase four Rangers. We weren’t able to purchase accomplished with a minimal number of attempts. A enough units for every ALS truck, so we decided to place 2004 study showed an increase in complications follow- one on each of the rescue lieutenant’s vehicles and one on ing the second attempt at oral tracheal intubation.1 The our medical helicopter. Rescue lieutenants and flight study reported that hypoxemia occurred in only 11.8% of medics are the only ones who perform RSI and they patients intubated within two attempts; however, hypox- respond to most of the critical calls. With this strategy, we emia was seen in 70% of patients on whom more than felt the Rangers would be quickly available anywhere in two attempts were made. Aspiration went from 0.8% the county.

ELSEVIER PUBLIC SAFETY THE PERFECT VIEW 19 Using Is Believing, continued from page 19

CASE STUDY #1 CPAP was attempted but discontinued within a few Early one morning, one of our stations responded to a minutes because the patient was too weak and tired. motor vehicle crash (MVC) in which a motorcycle struck Respirations were assisted with BMV while an IV was a pickup truck broadside at a high speed. The driver of the established. Lasix 80 mg was administered, but morphine motorcycle was lying approximately 75 feet from the and nitroglycerine were withheld due to her hypotension. point of impact and was unconscious and unresponsive. A second IV was established, and a dopamine drip was No helmet had been worn (they’re optional in Florida) at started with the hope of increasing her BP enough to the time of the accident. allow for the administration of additional medications. Physical assessment revealed unequal pupils and blood in The patient’s condition continued to deteriorate, and the patient’s ears, nose and mouth. He had shallow respira- an attempt at nasal intubation proved unsuccessful. A tions at four to six a minute and uneven chest rise. supervisor dispatched on the call decided, in conjunction Examination of the extremities revealed bilateral femur with the scene paramedic, to use RSI and attempt to fractures. His other vital signs were: Pulse 130, weak and orally intubate the patient. The crews realized it would regular; blood pressure 88/54; and SaO2 86. be a difficult intubation, but the patient needed an airway, Initial treatment included man- and with video laryngoscopy ual C-spine stabilization while available, team members felt con- crew members attempted to assist fident they would be successful. ventilations with bag-mask ventila- The patient was paralyzed and tions (BMV). Because his jaw was successfully intubated using the clenched, the ventilations were Ranger on the first attempt. ineffective. It was obvious that if the patient was to have any chance OTHER CASES & of survival, an airway needed to be IMPRESSIONS secured quickly. Due to the severe Our crews have also used the head injury and the clenched jaw, video laryngoscope successfully to few options were available. clear airway obstructions in two The crew decided to perform children. Visualization was quick, RSI and orally intubate the patient. and the design of the blade The patient was sedated and para- allowed more room in the mouth lyzed, and oral tracheal intubation to maneuver the Magill forceps. was attempted. The first attempt In instances when a supervisor was unsuccessful, and the patient’s arrives on scene where a patient pulse dropped to 52. The patient has already been intubated, but was then ventilated by BMV, the crew is unsure if the place- bringing his pulse back to 120. ment is correct, we have used the A rescue lieutenant arrived on Crew members from Martin County Fire Rescue train Ranger to quickly and easily veri- scene with a video laryngoscope, with the Ranger in the back of a rescue unit. fy tube placement by inserting the and the patient was successfully blade/camera into the airway. intubated on the first attempt. The patient was air lifted to Within a few seconds, several providers at once can confirm the local trauma center, and after several months of recov- placement on the video screen. Our flight medics also fre- ery, he was released to a rehabilitation facility to undergo quently use this technique to verify tube placement before physical therapy. A full recovery is expected. loading intubated patients into the helicopter. Many of our paramedics have said they also prefer the CASE STUDY #2 Ranger over traditional methods because they don’t have Whenever a difficult airway is mentioned, we naturally to put their face down by the patient’s. This decreases the think of trauma patients, but some of the most challenging possibility of bloodborne exposure from secretions or airway problems can arise from medical calls. Recently, one blood coughed up by a trauma patient. of our rescue crews responded to an “unknown medical” in After we put the Rangers in service, we took them to a mobile home park. On arrival, they found an extremely local emergency departments for demonstrations. The obese woman in her 50s in the back bedroom of a small physicians were impressed, and on several subsequent mobile home and in severe respiratory distress. An initial occasions, called for a rescue lieutenant when they had exam revealed her skin to be pale and diaphoretic, and rales a difficult intubation and an anesthesiologist wasn’t were noted in all lung fields. Her pulse was 140, BP was available.

74/48, SaO2 was 54%, and respirations were six a minute, During the past nine months, we’ve used video laryn- with cyanosis noted around her lips. goscopy on 72 prehospital patients and successfully

20 THE PERFECT VIEW ELSEVIER PUBLIC SAFETY intubated all but one. When I performed a quality assur- To date, we haven’t had an intubation attempt delayed ance review on the failed intubation, I determined it was and the paramedics haven’t exhibited any decline in tra- most likely due to an inexperienced operator error. After ditional laryngoscopy skills. A strong quality assurance that case, our rescue lieutenants provided refresher training program should keep this from happening. for all crews, and the problem hasn’t happened since. Although the controversy over prehospital oral tracheal intubation still rages, I believe the endotracheal tube is the GETTING STARTED best and most secure airway available. I’m not recommend- I can’t stress enough the importance of training for any- ing that every ALS unit carry a video laryngoscope, but one who may have the opportunity to use this equipment. I strongly urge departments, especially those using RSI, The procedure isn’t difficult; it’s just different than the to find a way—through grants, private donations or way paramedics were originally trained to intubate with a fundraisers—to obtain units and place them strategically traditional laryngoscope. The design and shape of the within their service area. The results of your efforts, in blades actually make intubation easier and require much terms of improved patient care, will be priceless. less force to visualize the vocal cords. However, if you aren’t comfortable with the equipment, you can feel awk- REFERENCES ward during your initial attempts. 1. Mort T:“Emergency tracheal intubation: Complications associated with repeated I recently had a discussion with a physician who was laryngoscopic attempts.”Anesthesia & Analgesia. 99:607–613, 2004. concerned that paramedics may become too reliant on the Ranger and felt it could reduce their ability to intu- David Zarker, EMT-P,is a rescue lieutenant with Martin County (Fla.) Fire bate the “traditional way” if the device was unavailable. I Rescue. He previously served as the program coordinator for LifeStar, definitely understand this concern, especially if every Martin County’s air medical program,and was involved in creating a public/ ALS unit carries a video laryngoscope, but in our service private partnership in order to bring an affordable air medical program to we expect paramedics to attempt to secure the airway Martin County. He’s also active in protocol development, research and with their available equipment and not wait for a rescue development.Contact him at [email protected]. lieutenant to arrive with a Ranger. Disclosure:The author has reported no conflicts of interest. Teaching the Airway Designing Educational Programs for Emergency Airway Management

BY MICHAEL F. MURPHY, MD; RON M. WALLS, MD;& ROBERT C. LUTEN, MD

mong all emergency care providers, com- This program, which has trained more than 3,000 emer- petency in managing the airway is essen- gency providers, has undergone progressive improvement tial to managing patients who are acutely and innovation, and is now called The Difficult Airway ill or injured. Generally, the situation is Course: Emergency. It’s one of a family of educational pro- emotionally charged, the circumstance grams that now includes The Difficult Airway Course: is urgent, and the stakes are high. The EMS, and The Difficult Airway Course: Anesthesia. practitionerA must know what to do and when to do it. In the development of these programs, we recognized Having committed the past two and a half decades of our the importance of both cognitive and skill components in professional careers to teaching airway management, it still training clinicians on airway management, and incorpo- strikes us how difficult it is to effectively teach airway man- rated those components into a comprehensive and agement skills and to have students demonstrate learning. effective curriculum. So what does it take to successfully So much so that in the mid 1990s, we (with Dr. Bob educate EMS providers on airway management? Schneider) created a dedicated educational program for emergency practitioners to provide a comprehensive HOW WE APPLY LEARNING immersion experience in emergency airway management, When a clinician encounters an airway emergency, each with a special emphasis on the identification and manage- step of the assessment and intervention process is poten- ment of the difficult and failed airway. tially challenging. The cognitive piece of response—

THE PERFECT VIEW 21 Teaching the Airway,continued from page 21

the “what”—involves a multitude of parameters, including odds of making appropriate treatment decisions. knowing the anatomy, physiology and pathophysiology of Mnemonics are useful in guiding the practitioner in the airway; knowing how to evaluate the airway; under- rapidly evaluating the airway for difficulty with respect to standing the what, how and when of medications used in management options, including bag-mask ventilation airway management; and deciding the best method of man- (BMV), the use of extraglottic devices (EGDs), laryn- agement and the best time to intervene. goscopy and intubation, and surgical airway management. The competent, well-trained provider has the ability to Two of the mnemonics used in The Difficult Airway apply this knowledge Courses are shown in Figure 1.3 On the WEB: For other mnemonics to to actual cases in such a help with airway management, go to jems.com manner that the most DEVICES TO DISCUSS and search “Helpful Mnemonics.” appropriate action is Some techniques and devices for airway management are taken. Thus, the train- so established that they constitute the standard of care and ing must involve acquiring the technical and cognitive skill must be taught in any program. Examples include BMV, sets needed to manage the airway and knowing how to res- laryngoscopy and orotracheal intubation, and cricothyro- cue the situation (and the patient) “if the wheels come off.” tomy. That’s not to say they must be taught as first-line Essentially, practitioners deal with critical incidents with interventions, but simply that they must be taught within one of two basic mechanisms—by either a rule-based solu- the scope of the educational program. tion or a knowledge-based solution.1,2 The marketplace is flooded with airway management To reach a rule-based solution, the practitioner recognizes devices. The reason is clear: Airway management is difficult, the event for what it is. They identify and apply a solution and the ideal device that’s easy to use and guarantees near that experience has shown will likely be useful in solving the 100% success has yet to be invented. So it’s left up to those problem. Recognizing the event involves a process called with expertise in the field to select the devices perceived to “similarity matching” or “pattern recognition,” which deliver an advantage over what currently exists—decisions means we recognize characteristics of a current event as that are, where possible, backed up by good scientific evi- being similar to those of past events. This process assumes dence. Some of these devices and techniques include the they’ve had sufficient experience with both the situation intubating stylet, EGDs, rigid and semirigid optical and the application of the rule to immediately recognize the stylets, video laryngoscopes, and flexible fiber optics. problem and to know which rule to apply. Sometimes, a device or technique has particular rele- This ability constitutes vance to the practice envi- what’s called “expertise.” ronment of one audience Unfortunately, difficult and not another. The best and failed airways are example is the prehospital encountered infrequently environment, where ster- in practice, and the indi- ilization of reusable vidual experiences of the devices isn’t ordinarily vast majority of practi- possible, rendering an tioners is unlikely to have advantage to single-use been sufficient to earn devices (e.g., disposable them “expert” status. versus reusable EGDs, or N A

M ®

A knowledge-based L the GlideScope Cobalt L E

solution is a ground-up, E instead of the GlideScope N E L

first-principles strategy G Ranger). whereby the practitioner, Integrated didactic teaching, case studies and skills development—such Importantly, there are without substantial past as this cadaver lab—provides the best educational experience. devices that are not taught experience with similar because they may require situations, attempts to find an appropriate solution. Not high-frequency use to maintain competence, are too surprisingly, such strategies are time-consuming, and, if expensive or confer little advantage over simpler devices forced under pressure, are more likely to result in failure. or techniques. However, most emergency airway managers don’t have sufficient clinical experience with difficult airways to SKILLS INSTRUCTION have in their minds a rule-based, organized approach Part of the reason health-care providers find airway man- to these airway dilemmas, nor the time to build one from agement stressful is that some of the fundamental skills first principles. For this reason, a variety of tools, such as are difficult to master and, generally, poorly taught. mnemonics and pre-formulated airway algorithms, have BMV is one of those skills. It’s at least as difficult to been crafted to aid rapid decision-making and increase the master as laryngoscopy and intubation. It requires a

22 THE PERFECT VIEW JOURNAL OF EMERGENCY MEDICAL SERVICES I Figure 1> Helpful Mnemonics for Airway Management Difficult Bag-Mask Ventilation: MOANS M Mask Seal substantial amount of manual dexterity and practice to O Obese: BMI > 26 kg/m2 (or Obstructed airway) become proficient, and remain proficient. Because of A Aged: > 55 years this skill difficulty, it’s worth considering why BMV hasn’t N No teeth S Snores or Stiff been relegated to a subsidiary position in the basic airway management of the unresponsive patient in favor Difficult Laryngoscopy & Intubation: LEMON of easily taught and learned EGDs, such as the L Look externally: If the airway looks difficult, it probably is Combitube, King LTS or the LMA Fastrach. E Evaluate 3-3-2: Evaluate the geometry of the upper airway Laryngoscopy and orotracheal intubation together are M Mallampati score: Mallampati I-IV O Obstruction (upper airway) or Obesity renowned as a difficult technique to master. Roughly 50 N Neck mobility: The ability to position the head and neck orotracheal intubations are necessary to establish “competence” in the technique, defined as a 90% chance of success.4 It’s a highly nuanced technique that requires detailed SUMMARY step-by-step teaching. The program of instruction must Gas exchange is fundamental to airway management. emphasize those nuances (e.g., the importance of exerting Programs that teach airway management must embrace pressure on the hyoepiglottic ligament when performing this dictum and design objectives to achieve this program a curved blade intubation, employing an intubating stylet goal. Airway management has important and interrelated to facilitate intubation, how BURP is correctly per- cognitive and skill components. Thus, educational pro- formed). Even the specific motions of the endotracheal grams that provide an element of didactic teaching, case tube during insertion are critical to master. studies that apply and reinforce the didactic content, and An educational program must identify the “tricks” that skills teaching in a realistic simulated environment are enhance success—that little maneuver that makes “the last best suited to the acquisition and long-term retention of 5%” successful. At the same time, the program must rein- airway-management skills. force true principles of management (e.g., leave the den- tures in to bag ventilate, but remove them to intubate) and Michael F.Murphy, MD, is the professor and chair of anesthesiology and a debunk well-established but incorrect dogma (e.g., smear- professor of Emergency Medicine at Dalhousie University,the district chief ing K-Y Jelly on a beard makes BMV easier). of anesthesiology for the Capital District Health Authority,and an attending Virtually all the devices mentioned in the “Devices” sec- physician in Emergency Medicine at Queen Elizabeth II Health Sciences tion require detailed step-by-step instruction with respect Centre in Nova Scotia.Contact him at [email protected]. to patient selection, standard technique and modifications Ron M. Walls, MD, is the chair of Emergency Medicine at Brigham and in specific situations to achieve success—some more so Women’s Hospital and a professor of Medicine at Harvard Medical School than others. For example, optical stylets and video laryngo- in Boston,Mass. scopes may be of limited value in the bloody airway, and it’s Robert C. Luten, MD, is a professor of Emergency Medicine and easier to teach (and learn) the provision of gas exchange to Pediatrics at the University of Florida in Jacksonville. an unresponsive patient with a King LTS than to use BMV. Disclosure: Drs. Murphy and Luten have reported no conflicts of inter- Instruction on BMV is necessarily more intense than est. Dr. Walls has reported receiving honoraria from Verathon Inc. for a Combitube insertion because the former is a more difficult speaking engagement in 2007. technique to master. REFERENCES EDUCATIONAL PLATFORMS 1. Murphy MF,Crosby ET:“The algorithms.”In Hung OR, Murphy MF (Eds.): Difficult It’s clear from the literature that no single method of edu- and Failed Airway Management. McGraw Hill: New York, 2008. pp. 15–28. cation—classroom lecture alone, case studies alone, skills 2. Walls RM:“The emergency airway algorithms.” In Walls RM, Murphy MF (Eds.): labs alone—adequately teaches complex cognitive and Manual of Emergency Airway Management, 3rd edition. Lippincott, Williams and technical skills, such as airway management, and is consis- Wilkins: Philadelphia, 2008. pp. 8–22. tent with our experience over decades of education of 3. Murphy MF,Walls RM:“Identification of the difficult and failed airway.” In Walls health-care providers at all levels. A method of instruction RM, Murphy MF (Eds.): Manual of Emergency Airway Management, 3rd edition. that integrates didactic teaching, case studies and skills Lippincott,Williams and Wilkins: Philadelphia, 2008. pp. 81–93. development provides the best educational experience. 4. Mulcaster JT, Mills J, Hung OR, et al:“Laryngoscopic intubation: Learning and Simulation has emerged as a key educational resource in performance.”Anesthesiology. 98(1):23–27, 2003. areas where cognitive and technical factors combine to 5. Silverman E, Dunkin BJ,Todd SR, et al:“Nonsurgical airway management training force the participant to judge the best course of action. The for surgeons.”Journal of Surgical Education. 65(2):101–108, 2008. evidence from the literature suggests that simulation 6. Kory PD, Eisen LA,Adachi M, et al:“Initial airway management skills of senior residents: enhances performance and that this performance enhance- Simulation training compared with traditional training.”Chest.132(6):1927–1931,2007. ment is sustained.5 Evidence also supports the idea that 7. De Lorenzo RA,Abbott CA:“Effect of a focused and directed continuing education simulation enhances skills development in airway manage- program on prehospital skill maintenance in key resuscitation areas.”Journal of ment, reducing the need for actual live patient training.6,7 Emergency Medicine. 33(3):293–297, 2007.

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