Introductory/onboarding training for Video Laryngeoscopy, specifically for the MacGrath VL.
NOTE: This is meant to be part of a larger educational endeavor including online, hands on, and team based training.
Ellen O’Sullivan presents an outline of the Difficult Airway Society (DAS) Guidelines on airway management.
Airway management is a fundamental responsibility and skill of all involved especially for emergency physicians, anaesthetists and critical care physicians.
Ellen makes the point that mismanagement of airways leads to severe morbidity and mortality.
She provides a few harrowing examples.
The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to implement when tracheal intubation fails.
They promote patient safety by prioritising oxygenation and minimising trauma. Furthermore, they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training.
The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking.
They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed. The guidelines recommend videolaryngoscopy and second generation Supraglottic Airway Devices. All anaesthetists, intensivists and emergency medicine physicians should be able to use these devices.
There is limited evidence relating to the management of the ‘can’t intubate can’t oxygenate’ situation (CICO) PLAN D. However, all anaesthetists should be able to perform a surgical cricothyroidotomy (and trained accordingly).
Join Ellen as she provides you with what you need to know for management of the difficult airway, in line with the DAS Guidelines.
For more like this, head to our podcast page. #CodaPodcast
airway management by comparative study beyween Airtraq and McGrath Videolaryngoscope and Classical Macintosh in neutral neck position (stimulated cervical injury scenarios)
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
LSG exposes severe complications occurring in patients with benign condition.
Endoscopic stents entail high failure rate.
Total gastrectomy is required in one third of the cases.
Ellen O’Sullivan presents an outline of the Difficult Airway Society (DAS) Guidelines on airway management.
Airway management is a fundamental responsibility and skill of all involved especially for emergency physicians, anaesthetists and critical care physicians.
Ellen makes the point that mismanagement of airways leads to severe morbidity and mortality.
She provides a few harrowing examples.
The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to implement when tracheal intubation fails.
They promote patient safety by prioritising oxygenation and minimising trauma. Furthermore, they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training.
The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking.
They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed. The guidelines recommend videolaryngoscopy and second generation Supraglottic Airway Devices. All anaesthetists, intensivists and emergency medicine physicians should be able to use these devices.
There is limited evidence relating to the management of the ‘can’t intubate can’t oxygenate’ situation (CICO) PLAN D. However, all anaesthetists should be able to perform a surgical cricothyroidotomy (and trained accordingly).
Join Ellen as she provides you with what you need to know for management of the difficult airway, in line with the DAS Guidelines.
For more like this, head to our podcast page. #CodaPodcast
airway management by comparative study beyween Airtraq and McGrath Videolaryngoscope and Classical Macintosh in neutral neck position (stimulated cervical injury scenarios)
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
LSG exposes severe complications occurring in patients with benign condition.
Endoscopic stents entail high failure rate.
Total gastrectomy is required in one third of the cases.
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
Emergency sonography in Pediatrics has evolved to become one of the most versatile
modalities for diagnosing and guiding
treatment of critically ill patients.
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN Consultant Pathologist Lifecare Centre
HISTORY
Papanicolaou first reported in 1923 that cervical cancer or precancer could be detected by pap smear.
But it was only in 1943 that Pap test became accepted and widely used.
Many terminologies were used. Mostly numbers and term dysplasia. There were multiple poorly defined gradations which were poorly reproducible.
In 1988 the first Bethesda System workshop was convened to address the issue and to standardize the reporting of pap smear.
In 2001 a consensus was achieved and a terminology was recommended The 2001 Bethesda System (TBS)
Revision agreed upon in 2014
Laparoscopic surgery. Intro. History of Armata manus laparoscopic simulatorsDmitriy Shamrai
Introduction to lap.surgery - different laparoscopic techniques, equipment, instruments, benefits of laparoscopy for surgeons, hospitals and patients, laparoscopic education, Armata manus laparoscopic training and basic exercises.
Advanced exercises and IInd generation boxes with moveble camera are not shown here.
This presentation was reported during the I Laparoscopic school (by Armata manus).
P.S.: originally my or edited slides are marked by Armata manus symbol. Other slides were found in the Internet.
P.S.S.: contact author (shamraydv@gmail.com, facebook.com/dmitriy.shamrai).
Our page: armata-manus.com.
Airway decontamination - the dark side of airway managementscanFOAM
This is Jim DuCanto's talk at the airway session at The Big Sick 2018 in Zermatt.
It centers on his SALAD technique of continued suctioning throughout the intubation period.
More talks to be found at https://scanfoam.org/
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdfRobert Cole
(note: This presentation contained videos not included in this slide deck)
Describe the elements of Negligence
Describe the concept of vicarious liability
Describe the role of anchor bias, fatigue, anger and fear in EMS decision making
Review the case of Kyle Vess
Review the case of Paul Tarashuk
Review the case of Crystal Galloway
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
Emergency sonography in Pediatrics has evolved to become one of the most versatile
modalities for diagnosing and guiding
treatment of critically ill patients.
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN Consultant Pathologist Lifecare Centre
HISTORY
Papanicolaou first reported in 1923 that cervical cancer or precancer could be detected by pap smear.
But it was only in 1943 that Pap test became accepted and widely used.
Many terminologies were used. Mostly numbers and term dysplasia. There were multiple poorly defined gradations which were poorly reproducible.
In 1988 the first Bethesda System workshop was convened to address the issue and to standardize the reporting of pap smear.
In 2001 a consensus was achieved and a terminology was recommended The 2001 Bethesda System (TBS)
Revision agreed upon in 2014
Laparoscopic surgery. Intro. History of Armata manus laparoscopic simulatorsDmitriy Shamrai
Introduction to lap.surgery - different laparoscopic techniques, equipment, instruments, benefits of laparoscopy for surgeons, hospitals and patients, laparoscopic education, Armata manus laparoscopic training and basic exercises.
Advanced exercises and IInd generation boxes with moveble camera are not shown here.
This presentation was reported during the I Laparoscopic school (by Armata manus).
P.S.: originally my or edited slides are marked by Armata manus symbol. Other slides were found in the Internet.
P.S.S.: contact author (shamraydv@gmail.com, facebook.com/dmitriy.shamrai).
Our page: armata-manus.com.
Airway decontamination - the dark side of airway managementscanFOAM
This is Jim DuCanto's talk at the airway session at The Big Sick 2018 in Zermatt.
It centers on his SALAD technique of continued suctioning throughout the intubation period.
More talks to be found at https://scanfoam.org/
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdfRobert Cole
(note: This presentation contained videos not included in this slide deck)
Describe the elements of Negligence
Describe the concept of vicarious liability
Describe the role of anchor bias, fatigue, anger and fear in EMS decision making
Review the case of Kyle Vess
Review the case of Paul Tarashuk
Review the case of Crystal Galloway
2018 Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiop...Robert Cole
Bag-mask ventilation (BMV) is a less complex technique than endotracheal
intubation (ETI) for airway management during the advanced cardiac life support phase of
cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest.
It has been reported as superior in terms of survival.
1963 COWLEY Clinical Shock: A study of the Biochemical Response in Man.pdfRobert Cole
Accession Number: AD0427998
Title: CLINICAL SHOCK; A STUDY OF THE BIOCHEMICAL RESPONSE TO INJURY IN MAN
Descriptive Note: Annual progress rept. 1 Jan-31 Dec 1963
Corporate Author: MARYLAND UNIV BALTIMORE SCHOOL OF MEDICINE
Personal Author(s): Crowley, R. A.
Report Date: 1963-12-31
Pagination or Media Count: 226.0
Abstract: Traumatic shock is associated usually with severe injury and characterized principally by inability to maintain an adequate circulation. This study focuses on the total problem - the reaction of the body to injury, maintenance of life, and repair of injury. Studies currently in progress and those proposed are aimed primarily to understanding the biochemical response to injury in man. Provisions have been made for careful metabolic studies in the shocked patient without interfering with obvious life saving measures. Such extensive studies have required the assembly of a considerable staff - professional and technical - to support a C.S.U. on a 24-hour basis. Experimental problems relevant to establishment of such a unit evolved from two major factors 1 original nature of the study a scientific study of shock in man and 2 an unprecedented design of this study. Solutions to these problems are described. Since inception of the contract January, 1962, some 200 patients have been studied as they have undergone resuscitation measures. Final organization of the unit now permits more complex studies into the physio-biochemical response to injury in man.
Descriptors: *ENDOTOXIC SHOCK BACTERIA ENZYMES METABOLISM AMMONIA THERAPY HYPOXIA PHYSIOLOGY WOUNDS AND INJURIES IMMUNOLOGY CARDIOVASCULAR SYSTEM HYPOTHERMIA TOXINS AND ANTITOXINS HEMORRHAGE BLOOD COAGULATION
Subject Categories: Stress Physiology
Distribution Statement: APPROVED FOR PUBLIC RELEASE
Proposal to establish a new training center for Multi Agency EMS Training v1....Robert Cole
Vision
The Joint Emergency Medical Services training Center (JEMSTC) is a multi-use campus
and facilities dedicated to the provision of EMS and public safety education in the Ada
County-City Emergency Medical Services System. It would serve as a locus of collaboration and
effort in EMS education, providing not simply classroom space, but a relevant, dynamic,
realistic, and effective learning capacity, ultimately affecting the provision of all EMS services in
a positive way.
The JEMSTC would provide facilities for 24 /7 EMS education, vehicle operation, skills
practice, and credentialing. The facilities would be able to accommodate both EMS and Fire
apparatus in all climates for a diverse array of educational activities. This JEMSTC would meet
all the EMS (and related operational) training for the ACCESS system.
This document from • The Centers for Medicare & Medicaid Services shows that refusing to accept reports or parking EMS patients on the wall may be an EMTALA violation.
Hospitals and administrators do not want line EMS providers to know this, but this is ammo against abuse of EMS systems by ER Staff.
Improving Drug Calculation Performance in Paramedics Practicing in an Emergen...Robert Cole
This literature review will examine the scope of the problem and challenges with mathematical proficiency in out-of-hospital care. It will also explore interventions targeted at improving performance in the out-of-hospital environment, and how they may be applied in initial and continuing education models. The author hopes that improvement in drug calculations will result in fewer medical errors and improved patient care.
Access ce - 2021 11 pregancy induced hypertensionRobert Cole
Monthly CE for hypertensive emergencies in pregnancy for EMS providers.
Please note it is broken into sections
Also, Please note that the author has no problem with properly trained midwives, nurse midwives, and other providers with training in OB. The author does have a problem with providers who do not have specialty evidence-based training in OB presenting themselves as being able to provide appropriate care to a pregnant patient, particularly when such care is outside of guidelines and outside of the support of the larger healthcare system to handle the unexpected. The author has specifically been on cases where mothers and/or babies have been mismanaged by chiropractors, naturopathic doctors, and lay (unlicensed, minimally or completely untrained) midwives. Formally trained midwives, nurse-midwives, and other providers are an essential part of the larger healthcare system and provide culturally relevant and ethical care that is still supported by the larger healthcare system to reduce fetal and maternal mortality.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
3. Objectives
• Discuss the use of Video Laryngoscopy in the out of hospital setting
• Review the ACCESS SWO for Advanced Airway Management
• Describe the skill of Video Laryngoscopy using the Stryker McGrath
Mac video Laryngoscope using size 1-4 Mac Blades and the McGrath
“X Blade”
• Describe strategies and best practices for the use of video
laryngoscopy in the ACCESS system
• Review confirmation of placement of the endotracheal tube
• Review post intubation management
4. Tasks
• By the end of this training:
• Discuss and practice Direct Laryngoscopy (DL) AND Video Laryngoscopy (VL)
• Complete skills practice for VL using:
• Adult
• Pediatric
• Infant
• Complete Checkoffs for:
• DL/VL
• MAI
• SGA
5. Video Laryngoscopes
• 1970s – Fiberoptic Scopes (bronchoscopes, etc) used to place ETT
• 1990s – Fiberoptic Laryngoscopes
• 1998 – First VL prototype
• Early 2000s – Commercial VL (Glidescope) became common in ORs
and ICUs
• 2013 – American Society of Anesthesiologists recommended VL for
first attempts and standard equipment in OR's
• 2017 – Difficult Airway Society (DAS) recommends VL for First
Attempt and for difficult airway management
• 2022 – AHA VL in cardiac arrest: VL had better FPS
6. ACP approach to VL
• Groundwork pre-covid in 2018.
• Covid slowed everything
• Mid COVID AHA paper supporting VL and ETT over SGA
• 2020 review of Airway Success rates and possible solutions
• ACCESS Advanced Airway Course
• Improved airway onboarding in academy
• Pursuit of VL via grants and matching funding
• 2023 VL – 20+ units and disposables -
• EMSAVE Grant FY 23 (round 1) – 5 VL
• EMSAVE Grant FY 23 (round 2) – 5 VL
• ACP FY 23-24 budget – 10 VL
9. “To Long: Didn’t Read”
• Video Laryngoscopes:
• Improved view of Glottic Opening
in most cases
• The more difficult the airway, the
greater the impact of VL
• Improved First Pass Success
• Improved (decreased) total
number of intubation attempts
13. Why the McGrath?
• Durable
• Small, light weight
• History of successful use in EMS with overall positive reports in EMS
and HEMS
• “Standard Geometry” Similar approach to direct laryngoscopy.
• NOTE: THERE ARE SOME KEY DIFFERENCES DISCUSSED LATER
• Size Range 1-4 Mac = Infant to adults
• “X Blade” = Hybrid hyperangulated blade for difficult adult
intubations
15. Types of Blades
• MAC VL Blades size 1-4
• Disposable
• Use with Bougie, Stylet or
similar
• X Blade – Approx size MAC
3
• Disposable
• ONLY use with a rigid Stylet
16. Blade Choice: What Size?
“I’m a Mac #4 blade for traditional laryngoscope. The
McGrath (MAC) #4 usually goes way too deep. The # 3
is perfect.”
-Craig Wheeler , Flight Paramedic
“I’ve found the 4 blade is often too big for even large
adults. ”
-Amanda Lawrence, Flight Nurse
17. Blade Choice: MAC or X Blade?
“X-blade for predicted difficult or as second line, in
my practice. Nothing wrong with choosing it first, but I
appreciate the DL&VL aspect of standard geometry
blades as DL is my most experienced technique ”
Chad Pomerleau,Flight Paramedic
“Also… personal preference is to default to the x-
blade. X-blade can be used on normal or difficult
intubations. A MAC3 or 4 can’t be used on
difficult intubations.”
-Kevin Travis, Training Officer
18. Deployment
• 1 McGrath VL on ALS transport units
• Deployment in ALS non-transport units TBD
• ETT Kit
• Size 3 and 4 McGrath Blade in ETT Kit
• X blade in ETT kit
• Ped Kit
• Size 1 and 2
• Back Up (wall)
• Sizes 1-4 (1 each)
• X Blade (1 each)
• Daily Check
• Battery Life – 250 minutes
• Swap at < 20 minutes
• Low batts will be given to Training for use in class
19. McGrath MAC
Daily Check
• Daily Check
• Battery Life – 250 minutes
• Swap at < 20 minutes
• DO NOT THROW AWAY.
• Swap with BCs
• Low batts will be given to
Training for use in classes
20. Cleaning the
McGrath
• 70% Isopropyl Alcohol (Blue top Wipes)
• Quaternary Ammonia + Isopropyl Alcohol
(purple Top Wipes)
• Remove battery before cleaning.
• Battery can be cleaned separately. Do not
replace until dry.
• Do not dip into IPA. Use wipes.
• Use only IPA on camera stick
• Do NOT use bleach (Orange Top) , or grey
top wipes.
22. Progressive Laryngoscopy
is essential.
• Do not “Shove it in and hope for
the best”
• “Progressive Laryngoscopy” is
essential. Even more so with VL
• Epiglottoscopy Laryngoscopy
Intubation
• Improves success rate
• Decreases patient injury
23. “Progressive
Laryngoscopy”
Methodically progressing down
the tongue to the epiglottis is a
simple roadmap to the larynx.
Vocalize as you go.
1. Tongue.
2. Still all tongue. Stay the
course.
3. The epiglottis appears.
4. Move into the vallecula and
lift.
24. Do not hyper-focus on the Camera
• VL is an important tool in managing the airway but one should be
aware of possible complications that can be avoided.
• Injuries have been documented by providers focusing on the camera
and being careless with passing the tube through the
oral/hypopharynx
• Significant potential for perforation of the oropharynx when the tip of
the ETT containing the rigid stylet is not carefully visualized all the
way back into the oropharynx before turning attention away from
the posterior oropharynx to the VL monitor.
• Use a “Mouth-Screen-Mouth” approach
25. GlideScope video laryngoscopic view of ETT perforating the
palatoglossal arch and soft palate. ETT, endotracheal tube.
Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J
Oral Maxillofac Surg 2016.
26. GlideScope video laryngoscopic view of ETT
perforating the palatoglossal arch and soft palate.
ETT, endotracheal tube.
Huffman et al. Video Laryngoscopic Oropharyngeal
Injury. J Oral Maxillofac Surg 2016.
29. “SALAD and VL”:
• “When training your people have them make a
habit of always using SALAD technique with
Ducanto suction even if the airway appears to
be clean.
- Stephen Wilcox, Flight Paramedic
30. “Laryngoscopic Paradox”:
• The camera can mislead your perspective and cause esophageal
intubation.
• Often the best “view” (grade 1) may result in lower success rates.
• A grade 1 view may be “too deep”.
• The “second best” view (grade 2) may result in better success.
31.
32.
33. “Laryngoscopic Paradox”:
• “With VL you can have “too good” of a view
that can obstruct your ETT placement.”
- Michael Revland,
Flight Paramedic Mayo Clinic
34. “Laryngoscopic Paradox”:
• “for some reason with the view from a single
point with the McGrath it seems remarkably
easy to go deep”
- Chad Pomerleau,
Flight Paramedic
35. “Laryngoscopic Paradox”:
• “Stress proper technique and placement in the
vallecula since it is a Mac style blade. Most failures
we have had in the field are from placing the tip
underneath the epiglottis and it being too deep.
• They get a great view of cords but the curve of the
blade can push the ET Tube towards the esophagus
when not placed right.”
- Chris Foerster,
Training Officer, Tx
• “It seems like no matter how many times you
train on this, most people still make this mistake
repeatedly in real life with actual missed tubes
before it finally sticks. Seen the same from both
medics and ED docs.
Greig Samuelson, Training Officer, S.C.
36. “Laryngoscopic Paradox”:
• “Go in with suction ahead of your blade (SALAD
technique) [avoids goop on your lens], gain a grade
one view then back up to a grade two view and go
bougie first every time regardless of predicted
difficulty“
- Derek Michael, Flight Paramedic
37. “Laryngoscopic Paradox”:
• “You back up to a grade 2 view bc the lens
placement in a grade one view will lead u to believe
you are going straight in, but in reality you’ll fight
to keep it out of the esophagus nearly every time.
With a grade 2 view you will be lined up perfectly.”
- Derek Michael, Flight Paramedic
38. “Laryngoscopic Paradox”:
• “Been using the McGrath for almost 5 years now.
Love it. My advise to anyone new. If you have a
poor view or having trouble passing a bougie or
Tube, back up. It’s almost always because the
blade is too deep.”
- C.J. Saunders, Flight Paramedic
41. Unrecognized (or recognized too late) Esophageal Intubation
occurs in up to 8% of prehospital intubations…why?
• MISTING IN TUBE 69%*
• Lung Sounds 14%*
• 5 point Lung Sounds 18%*
• (Adds Epigastic sounds to
assessment)
• EDD 9%*
Hansel, J., Law, J. A., Chrimes, N., Higgs, A., & Cook, T. M. (2023). Clinical tests for
confirming tracheal intubation or excluding oesophageal intubation: a diagnostic
test accuracy systematic review and meta-analysis. Anaesthesia, 78(8), 1020–
1030. https://doi.org/10.1111/anae.16059
42. Anchoring Bias: One false positive leads to
more false positives
NAEMSP Florida Chapter. (2023, August 30). Jan Hansel MD: Strategies to Confirm ETT placement
(8/29/23). https://www.youtube.com/watch?v=mDaq12pR4jM
43. “Glottic Impersonation” : VL Does NOT reduce
unrecognized esophageal intubations.
• VL can cause “false positive” too.
• VL does not reduce bias
• VL screens may mislead
providers
• The McGrath is vulnerable to
this.
46. “Sustained” ETCO2
• “Sustained” ETCO2 is defined as a minimum of 7
consecutive breaths. The ETCO2 is consistent or increasing
amplitude of the capnogram over 7 breaths.
• The level of CO2 rises and falls appropriately with exhalation
and inhalation.
• The peak amplitude/change of CO2 is a minimum of 7.5 mm
Hg above the baseline.
• The capnogram is clinically appropriate.
47.
48. Appendix 3.1 (Released NOV 2023)
• Assume esophageal intubation until proven otherwise by ETCO2
• EZ cap is only a bridge to wave form capnography
• Sustained ETCO2 is the gold standard.
Regardless of the use of VL, or the perceived “passing of
the tube” visualized on the camera, sustained ETCO2
remains the gold standard for confirmation.
“No trace, No tube”.
Background of VL
Fiber-optic scopes 1970’s
Fiber-Optics laryngoscopes early 1990s
First video prototype 1998
Weiss M. Video-enteroscopy: A new aid to routine and difficult tracheal intubation. British Journal of Anaesthesia. 1998;80:525-527. DOI: 10.1093/bja/80.4.525
1st commercial VL: The Glidescope 2001
2013 - the American Society of Anesthesiologists (ASA) suggested the use of video laryngoscopy as the first choice in airway management in its algorithm of airway management
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for the management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251-270. DOI: 10.1097/ALN.0b013e31827773b2
2015 - The Difficult Airway Society (DAS), in the 2015 algorithm, recognized the use of video laryngoscopy as part of airway management and suggested to all anesthesiologists the adoption of the video laryngoscopy skill
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for the management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2015;115:827-848. DOI: 10.1093/bja/aev371
2017 - DAS presented video laryngoscopy as an equivalent technique to direct laryngoscopy in the first attempts of intubation in the airway management algorithm in intensive care units (ICUs)
Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018;120:323-352. DOI: 10.1016/j.bja.2017.10.021
The McGRATH™ MAC VL uses “standard geometry” curved blades closely approximating Macintosh laryngeoscope blades used in DL. These blades come in sizes 1-4 closely approximating their DL counterparts. Blade selection is based on providers clinical judgement.
Clinical reports indicate that providers should “lead” the blade with a suction catheter and use a bougie when possible as a best practice.
The McGrath X Blade is a hyperangulated blade approximately the size of a MAC 3 blade. It contains a more “acute curvature” (hyperangulation) and slimmer blade than other McGRATH™ MAC VL blades. It is easily distinguished by it’s yellow label affixed to the blade.
70/30 IPA (Isopropyl Alcohol) is a low toxicity solvent made of a mix of 70% pure isopropyl alcohol and 30% water. This is generally the mixture used in first aid products such as rubbing alcohol.
Monitor: Ensure the 70% IPA wipe gets
into the various grooves around the
screen.
2. Monitor Hinge: Rotate the monitor
to the upright position. Feed the 70%
IPA wipe into the space between the
monitor and handle to ensure. effective
penetration. Rotate the monitor to its
opposite position and repeat.
3. Battery Bay: Ensure all surfaces of
the Battery Bay (with battery removed)
are thoroughly treated with the 70%
IPA wipe. Ensure that the join between
the battery module and the handle is
thoroughly treated with the 70% IPA
wipe.
4. Handle: Ensure all surfaces of the
handle are thoroughly treated with the
70% IPA wipe.
5. Clip and Heel Area: Take particular
care in ensuring that the small metal
clip feature is clean, in particular the
internal corner between the clip and the
surrounding plastic body.
6. Camera Stick: Ensure all surfaces of
the camera stick are thoroughly treated
with the 70% IPA wipe.
7. Camera Lens: Clean the camera lens
with the 70% IPA wipe, ensure that the
interface between the metal Camera
Stick and camera lens is clean.
Conceptually, direct laryngoscopy can be thought of as progressive visualization of intra-oral and pharyngeal soft tissue structures as the laryngoscope blade is advanced and landmarks are exposed. The laryngoscope blade functions as both a retractor and an illuminator during this process.
There are three “stages” to this process:
Epiglottoscopy
Laryngoscopy
Intubation
This works with both Mac and Miller. Cramming in the miller and withdrawing is a poor method and often causes trauma to the airway. Advancing while watching allows you to observe the airway, guide the tool and make better clinical observations and decisions.Additionally, identifying landmarks reduces the incidence of glottic impersonation.
Be mindful not to hyperfocus on the camera, and avoid injuries to the soft tissue structures of the airway by careless passage of the ETT. The most common injuries occur to the Tonsillar Pillars and soft pallet, but can occur to any structure. Soft tissue injuries commonly occur when the intubating provider concentrates on the video monitor and blindly inserts the GlideScope® into the oropharynx
. GlideScope video laryngoscopic view of ETT perforating the palatoglossal arch and soft palate. ETT, endotracheal tube.
Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J Oral Maxillofac Surg 2016.
Intraoral view of palatoglossal arch laceration with Dingman retractor in place.
Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J Oral Maxillofac Surg 2016
Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis
J. Hansel, J. A. Law, N. Chrimes, A. Higgs, T. M. Cook
First published: 16 June 2023
https://doi.org/10.1111/anae.16059
Citations: 2
30 studies in a meta-analysis. Most studies were at low risk of bias in most domains, and included a mix of human, animal and cadaver studies. As the studies were designed to distinguish between tubes placed in the trachea or oesophagus, this analysis determines the utility of the tests to confirm tracheal intubation and at the same time to exclude oesophageal intubation.
What are we saying here: That if you get a false positive on your first assessment, you are “anchored” to that assumption and more likely to disregard sunsequent assessments that contradict the original conclusion, even ETCO2.
One false positive will lead to 91-95% disregarding of a valid capnograph. Two false positives will lead to 99% disregarding of a valid capnograph. We must be aware of our own anchoring biases, and that not all assessments are “equal”.
All of these were believed to have visually pass through the cords.
Colormetric ETCO2:
Colorimetric ETCO2 (i.e. EZCAP) is inherently inferior to waveform capnography and is intended only as a bridge or backup if waveform ETCO2 is delayed.
Waveform ETCO2: As esophageal intubation is not necessarily always associated with a completely flat or absent ETCO2, the standard of a “sustained” ETCO2 immediately after placement of the advanced airway and through out patient care until transfer of care is required.
VL does not preclude accidental and unrecognized esophageal intubation. In some cases, mis-identifying landmarks and limited camera view lead to esophageal intubation. In other cases an over-reliance on VL and anchoring bias convinced providers into discounting clear signs of esophageal intubation. Providers should always be cognizant that no procedure nor technology is foolproof.