Saturday, May 12, 2012

A Web Curriculum for Learning Endotracheal Intubation

The Gist:  The airway is one of the fundamentals of emergency medicine.  It's imperative to be familiar with terminology and procedures associated with the airway.  Fortunately, there is a cornucopia of excellent information to make this easier for a beginner navigating endotracheal intubation and the airway in general. Below is a basic outline of the initial approach to learning endotracheal intubation, courtesy of the dedicated podcasters and bloggers.

Why is the airway important?  Without one, you don't have a patient.  Or, rather, you don't have an alive patient.  Furthermore, these procedures are fun, humbling, make an enormous difference on patient outcomes, and there's a unique exhilaration in the improvisation and collaboration that accompanies a difficult airway (like this one).  Also, with the amazing advent of video laryngoscopy, many attendings encourage utilization of these devices for the novice intubater.  These devices are great, but I think that solid comfort with direct laryngoscopy is important.  Best bet?  Arrange to do an anesthesia rotation during clerkships!

I had an incredible experience on my anesthesia rotation and realized that part of the experience was derived from the didactics I inadvertently received by following various podcasts and blogs.  I was so impressed with the information put out there by Emergency Medicine physicians that I felt others could benefit from this information and intervene on their first airway with confidence, skill, and knowledge.  Sure, much of the basic endotracheal intubation skill revolves around the sheer number performed but the experience is much more pleasant, beneficial, and interesting with a basic understanding.

Do you want to own the airway?  Everything one needs is here, courtesy of the fine folks at Life in the Fast Lane, the ultimate source for Emergency Medicine education on the web.  By far, the most comprehensive "all in one" reference.

EMBasic Airway Episode by Dr. Steve Carroll- I recommend subscribing to the podcast through iTunes. 
  • Airways exist on a spectrum of difficulty and one may be fooled into a false sense of security in the initial assessment of the airway.  Expect an airway to be difficult unless proven otherwise.  Dr. Carroll does a great job emphasizing this point.
  • Note, this podcast talks some about drugs used in Rapid Sequence Induction (RSI) and vaguely about rocuronium (a drug I prefer over succinylcholine), and this conversation, while part of the airway dialogue/process, shall be addressed would just be too cumbersome here.
EMCrit's Podcast 70 - Airway Management with Rich Levitan - This lecture is incredible.
  • In fact, the podcast came out roughly halfway through my anesthesia rotation.  I had been doing some things precisely wrong!  My intubations were significantly better after the explicit and methodical approach to epiglottoscopy and laryngoscopy.  Again, I recommend downloading the video via iTunes
EmCrit Procedure Video here - awesome, succinct...well done.

Explore the AirwayCam website for photographs and a plethora of information on instruments, techniques, and more.  This site is absolutely incredible.  For example, there's an entire section on the amazing bougie!

Pre-oxygenation!  This paper by Dr. Scott Weingart and Dr. Richard Levitan is essentially a cheat sheet to preventing the O2 saturation monitor from beeping (thereby inducing tachycardia in the amateur intubater) during intubation.  More importantly, I think this is beneficial for patients. 
  • ERCast video here.  Amazing!
This site by Dr. Minh Le Cong also has much to offer in airway education, although it's more advanced.

A Few Other Miscellaneous Pearls:
The ability to ventilate is paramount.  Check out EMCrit's Podcast Video 65 here (or download via iTunes)
  • Unfortunately, we learned how to bag a patient incorrectly in ACLS.  Lose the "E-C" technique and utilize the two handed technique described in the above video. 
This site discusses different techniques to predict difficult airways.
The mnemonic OBESE may predict those that will be difficult to mask ventilate.  The presence of two of the following indicators predict difficulty (with sensitivity and specificity around 70%).
  • Obese (BMI >26), Bearded, Elderly (>55 y/o), Snorers, Edentolous (No teeth) 
The LEMON score isn't near perfect but it can aid in the assessment of the airway.  The score has a maximum of 10 points with one point for each of the following. Higher score = increased difficulty. 
  • L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue)
  • E=Evaluate the 3-3-2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths) - perhaps the most predictive
  • M=Mallampati (Mallampati score of 3 or greater)
  • O=Obstruction (presence of any condition that could cause an obstructed airway)
  • N=Neck mobility (limited neck mobility).
Much much more to come on this issue.  In the future....drugs and scary, humbling, proactive and fun airways

Successful ETI is not solely passing a tube through the cords.  After intubation, there's still much to do.  Check out EMCrit's post-intubation package podcast.

Thanks to all of the incredible physicians and educators who create and disseminate this information.

1 comment:

  1. Hi Lauren and fellow readers,

    You might like the collection of free online videos we've put together on LITFL... its called 'Own the Airway!'