(Transcript is automatically generated)

Erik: [00:00:00] Then the wife came in and said, no, stop. Stop. He's DNR.

Matt: So it's really important to have good, a good team with you.

Narrator: You are listening to EMS with your hosts, Erik Axene and Matt Ball. 

Matt: Airway. This is, you're an airway guru. We've got guys that I work with that are airway gurus. I would not say that I'm an airway guru. I've certainly intubated my fair share of patients, but you have [00:00:30] for sure intubated way more than 

Erik: Lot of patients, and I've been humbled, no matter how good you are.

Yes. You've gotta maintain a level of humility. 

Matt: Yes. 

Erik: Yeah. Quick story.

Matt: I like 

Erik: story time with uncle Erik. I, again. More than a hundred thousand patients in my career. And a lot of airway in

Matt: not intubated. Just regular. 

Erik: Yeah. It's like that's a lot of intubations.

No, not that many intubations, but many intubations. Yeah. Yeah. You a lot. Anyway but I had a patient that came in that had been [00:01:00] getting a throat. Radiation for throat cancer. Oof. Yeah. And so his skin, he was in this kyphotic position.

Matt: I remember you've told me this story.

Erik: Yeah. And his skin was like plastic. And his chin was like on a sternum, and he came in with an eye gel in and it was working. Okay.

Matt: Was he in cardiac arrest or,

Erik: Yeah. Okay. Yeah, he was, he he was in cardiac arrest. They got him back. It was a mess. Okay. And they had an eye gel in, it was like, I need to get a definitive airway in this guy because he's not, it's not looking good.

Anyway, so I tried to intubate and I could not, [00:01:30] I tried, it's just he was in this terrible position. Yeah. And then his chins, no flexibility in his nothing. Couldn could not move him. And so I thought what's scary about him was I didn't have access to the neck to do a crike. My. Backup plan. Yeah. And if I can't get an airway as a crike, but I couldn't do that.

So I was setting up

Matt: 'cause of the positioning of his chin?

Erik: Yes. His chin was on his sternum. Oh wow. So you, oh, so I had no view. I couldn't see his neck.

Matt: That's scary.

Erik: And so I knew that if I couldn't get an intubation done, I would go to a retrograde [00:02:00] intubation. 

A guide wire. And then that's what I was planning to do.

Matt: Yeah. 

Erik: I couldn't do that either. Anyway, then the wife came in and said, no, stop. Stop. He's DNR 

Matt: I was gonna say a cancer patient that far along. Was he not a DNR? That was, 

Erik: I was hoping that would be the case. 'cause he was not well. And 

Matt: for his sake. Yeah. 

Erik: But anyway, so my, buddy of mine massive airway emergency came in because his jaw was wired shut.

There are lots of things that can happen. Had a patient intubated once, had a mass, like a tumor. At the airway. I couldn't see the vocal cord, just see a tumor.

Matt: [00:02:30] We saw that one time with a doctor that we both know was in the cadaver lab. Yeah. We were doing skills practice and we went into practice tubing and we're like, what is this?

Yeah. And this doctor went in and he, this was before video, he looked in and he's oh. It was the only time I've got a pretty strong will in the stomach. And he pulls out, he gets some McGill forceps and he starts pulling out this gigantic tumor. And I was like, oh God. It was the most disgusting thing.

And he's sitting there all into it, just yanking this. And I'm like, Ugh. [00:03:00] It was so gross. It was so nasty. But yeah, I would not want to run into one of those in the real World 

Erik: Point. Oh, I think that. I think I'd like to make is that no matter how good you are with airway, you've gotta maintain a level of humility.

Yes. 'cause airway can be tough for anyone Yes. In certain situations. But I think if you listen to the things we're gonna discuss here in the first half of our podcast you're gonna learn some skills or sharpen your skills for the things you can do to make things easier for yourself. 

So in the event that you do have a difficult airway, you're not making it any harder than it [00:03:30] already is.

And if you have a normal airway, you're not making things hard for yourself. 

Matt: Yeah. 

Erik: By setting things up properly and understanding how to approach the airway before the intubation ever happens. 

Matt: When I'm teaching airway stuff, I always say, you always cheat. This is the one time. Yeah.

You cheat and do everything in your favor. Like these guys, they don't, they want to use direct or they, instead of video. I'm like, why would you do that? Like initially, why would you do that? 

Why would you be intubating on the floor, you're working a cardiac arrest. Yeah. And if have the Torah criteria, you're gonna [00:04:00] transport your patient, why are you gonna be intubating them on the floor?

Get 'em up on the cot. Yep. Do put, stack the deck in your favor. Yeah. Stop doing all these things that are making it harder to get the tube right. Yeah. 

Erik: That's a really good. Really good point. 

Matt: Makes no sense to me whatsoever. But again, it goes back to training. And I think a lot of times with EMS, at least in my experience, teaching people the way, and I don't know if it's the same way with doctors.

And we've talked about this with the amygdala and change uhhuh that a lot of [00:04:30] EMS people, it's this is the way that I was trained. Fluid resuscitation with massive hemorrhage. Two large bore IVs. Pour the fluid to 'em. It's like it's sometimes it's hard to get people off of what they learned.

And it's no, that's killing your patient. Yep. Airway stuff, like I say with direct verse video, uhhuh, these guys are like. Now 

Erik: If you have a normal airway Yeah. And not something you've determined to not be a likely difficult airway. Go with whatever you're most comfortable with.

But in certain situations, yeah. Going with direct is hurting patients. Yes. Based on the [00:05:00] data. Yeah. You're gonna have the failed airway. Yeah. Which is of course a failed first attempt. So you're hurting your patient by not doing it in certain situations. 

Matt: What do you consider a failed attempt?

Just putting the laryngoscope in. Yeah, that's a good question. 

Erik: I think, yeah, if you stick the laryngoscope. Into view. And you don't establish a definitive airway. That was an attempt and that's a failed airway by definition. I'd agree. 

Matt: Yeah. I think that's the way it should be documented. And a lot of times we don't document, that's another issue.

We, we skip the Erik missed the airway and so had to come in and get it or vice, whatever the case may be. But [00:05:30] so patient assessment, you're looking at your patient, obviously you have a healthy adult. First off, I think it's. Obviously if they're in cardiac arrest, uhhuh.

We've talked about how super glottic airways are pretty much just as effective as innovation.

Erik: Yeah. PVM. Yeah. First car, sudden cardiac arrest goes, there's no, no need to be rush, no survival benefit to ET tubes. 

Matt: Back in the day when we had cprs, that was what everybody wanted. Let's get the tube right.

Yeah. And we're not doing good chest compressions. We're not doing the things that really matter. 

Erik: That's what really matters. Yes. Is that we're trying to keep the brain cells alive. [00:06:00] Absolutely. And by, by monkeying around with the airway. You could be jeopardizing the brain cells and, Hey, we got the definitive airway.

Yeah, 

Matt: great. Good for you, bro. But half the brain cells just died. We would always stop doing chest compressions when we'd go to intubate. There'd be minutes that would be going by where I'd be in there trying to intubate because we weren't told no. Don't do that. 

Erik: Focus should be on high quality chest compressions and minimizing interruptions.

That's what saves lives. Absolutely. There's no question. 

Matt: Yeah, absolutely. If you're intubating or ventilating, but you're not circling it. Yeah, it [00:06:30] doesn't matter, right? Yeah. It's not doing any benefit to your patient. 

Erik: Yep. 

Matt: So cardiac arrest aside, when to, I think one of the things for pre-hospital people is that when do you take an airway indications?

Erik: Yes, absolutely. That's probably the best thing we could talk about first. 

Yeah. 

Erik: So our three main reasons to intubate someone. It could be a like airway support. Maybe the work of breathing like a DKA patients. Breathing so hard. Now they're tired, so we gotta step into assist.

Matt: But now in the pre-hospital, not to interrupt you Yeah. But in the pre-hospital environment, there's a lot of [00:07:00] discussion about. You should be cautious innovating a DKA patient because that's their compensation for blowing off that acid. Correct. And not, we don't have vents. Now, if you have 'em on a vent in the hospital, it's a totally different story.

Erik: You're, if you do intubate a DK, a patient with pre-hospital environment out a ventilator, you know you're gonna have to have a high rate. 

Matt: Yeah. 

Erik: You're gonna be bagging faster than your typical once every six seconds. Because you've got it. You're right. And the reason we intubated that patient was airway support.

Because they're so tired. We're not really worried about patency issues. We could actually in this situation, but that's the other indication [00:07:30] I was going to say was airway. We supporting breathing. But then there's also airway patency issues, right? There's somebody who can't protect their airway.

So somebody who's maybe altered head injury vomiting and they're drunk, or they're, overdose GCs is score snar. Yeah. 

Matt: Fentanyl or, yeah. 

Erik: Yeah. Or GCs is zero, right? Yeah. No, but yeah, you got the patient that can't control their airway. That's another reason to intubate. And then the third reason to intubate would be a preemptive intubation for a condition that you know is coming, right?

Like a guy that in [00:08:00] fire inhalation or hot gas incident, something that air phylaxis. Yeah. Anaphylaxis, angioedema, stuff like that. Sepsis, all those, yeah. And then I would say the fourth one as like in parentheses would be for educational purposes. You intubate yourself because you wanna put it in a video.

Matt: How'd that work out for you?

Erik: Not good. 

Matt: And I, this might sound cruel, but I almost say in my department, we have a termination of resuscitation. Protocol. And a lot of times I, I look at it like if we're working, if we're in a nursing home and we're [00:08:30] working, 90-year-old grandma, who's been in asystole the whole time and we know her chance of coming back is next to nothing, that's good practice.

If I have a newer paramedic to say, Hey, let's attempt innovation on her. Because this is a real world rep that you can get in a real world environment with all the stressors 

Erik: with a potential difficult airway. The geriatric population. Correct. Notoriously difficult sometimes. Yes. Yeah. That's good.

So the indications. Yep. And the, those indications, you gotta know why you intubate or when to intubate. Yes. [00:09:00] That sometimes we're intubating people that don't need to be intubated. Correct. You can't just go GCs eight intubate. Yes. That patient might be postictal, you just give 'em a few minutes, they'll come out.

It might have low blood sugar. 

Yeah. Lots of factors that can play into that. A stroke patient. Yeah. 

And if you miss an emergency, you could be in a world of hurt because you should have intubated 10 minutes ago. Yep. So it's a, it's complicated. The indications it's important to understand and it's, and really know why 

Matt: it's teaching, it's teaching pre-hospital providers.

I've had, some people kick back why do we need to be RSI [00:09:30] patients in the field? Can't they just do that at the hospital 

Erik: Uhhuh,

Matt: we're five minutes from a level one trauma center. Can't they just do that there? And it's okay, if you have the major trauma patient 

Erik: uhhuh, 

Matt: Who's suffering a massive head injury?

We know that if they suffer any period of hypoxia, that dramatically decreases their chance of survival, right? Correct. So the quicker you can get that airway and keep their oxygenation up and ventilate for that patient, the better it is. And regardless of whether you have a five minute transport time, it's not five minutes before that patient's gonna get intubated.

Erik: Yeah, 

Matt: [00:10:00] you've gotta stabilize them, get 'em in the ambulance, get your IVs, whatever. Then you're driving, then you get out. You're looking more like 20 minutes. True. That's really bad for those patients. 

Erik: Now, I would say if you have a difficult airway and you're looking at this patient that you're able to ventilate your oxygen just fine.

And you know this is gonna be a difficult airway for some reason, I don't know what it is. And you know that you and your partner don't have a ton of experience. I'm just painting a picture maybe Yep. Of going in there and just giving it a try. Yeah. May not be the right [00:10:30] choice depending upon how close you are to the facility and how far away you are and how difficult the airway may be.

There may be some difficult airways that they're gonna die if you don't do it now. You gotta, again, you gotta understand the pathophysiology of airway and then once you've made that decision, it may be better to wait and, yeah. Go done A controlled environment. 

Matt: Absolutely. I've done that with patients.

Were going to the hospital and they were on CPAP and they started going downhill, but it's like there was a, it was a bigger patient and I'm thinking. I'm less [00:11:00] than two minutes from the ER and we're still setting. Okay. Yeah. End titles still. Okay. But they're starting to go out because of the work. I'm like, I'm not gonna pull over and go through this whole process of doing this.

Yeah. On a difficult airway, it made more sense just to, Hey, let's just keep going. 

Erik: Yep. 

Matt: And get there to more help. 

Erik: Yep. 

Matt: In a more stable environment. That way if we don't get the airway, we've got a lot more resources. 

Erik: Situational awareness. 

Matt: Yes. And that comes with experience. Yep. 

Erik: And you've gotta know your experience.

And then you gotta understand too, that at the ER, they're going to [00:11:30] have not only the ER doc and all the airway team, the RT and yourself is part of the team too. Yes. Yeah. You're gonna have anesthesiology right there, and you've got all these other cool tools. Yes. Bronx and all sorts of neat stuff. Yes. Not delaying the care definitive care could be the right choice.

Matt: And we're not suggesting that if you. I feel like your patient has indicated you have a head injury patient and you're like, their GCs is four. They're not sat very well. They're breathing, three times a minute or whatever. They've got Cushings, like that patient needs to be intubated right now.

Erik: Yeah. 

Matt: You gotta [00:12:00] put that patient down. You gotta intubate that patient. We're not suggesting Oh, wait till you get to the hospital 'cause they have more resources. No. There are times when that's applicable. But there are times when, like you said earlier, their patient's unstable, they need an airway.

Erik: I think What people look for is those easy, just tell me what to do and when to do it. Yeah. It's not that simple. No, it's not that easy. It's not that it's not, there's always, every patient's different. You've gotta have a real keen understanding of your own limitations. Limitations of your environment. Patient airway and how difficult it might be. Yeah. And then your capabilities of your hospital. It's all together. And then how far away are [00:12:30] you? 

Yeah. 

Erik: There's so many conditions that. Factor in and then your own fac, I mean your L video endoscope might be out.

Oh, shoot. What happened to the battery? Yeah. Whatever. There's so many factors. Yeah. That's a bag checkoff problem if your battery's true. True. But the plastic tube that I would insert in the ER is oddly similar to the one you would use. In the A. Exactly. 

Matt: Yeah. Most of the meds are the same and yeah.

Yeah. That's what I'll always tell people is. If you have the ability or if when you get to the hospital if you do something [00:13:00] within the first five or 10 minutes to that patient that I had the ability to do pre hospitally, I probably should have done that pre hospitally. Yes. Whether it was a medication or intubation or something like that.

If, I know as soon as I get to the hospital, this patient's gonna be inated again. Situational, dependent. 

Erik: Yeah. 

Matt: But, and you're not doing it because you're uncomfortable doing it then? You need to get comfortable doing it. Yeah. You need to get those airway mannequins out.

You need to be practicing. Failed airway. Okay, what happens if I don't get this 

Erik: right? I know 

Matt: a lot of pre-hospital guys, they're worried about [00:13:30] paralytics. 

Erik: Yeah.

Matt: What if I can't give the tube after I've given a paralytic? 

Erik: Yeah. 

Matt: Okay. I had a doctor tell me one time, if you can ventilate and maintain or increase O2 SATs before you push the paralytics, you shouldn't have any fear of pushing the paralytics. 

Erik: No. 

Matt: Because if you push it and you can't get it, okay. Throw in a superlo airway or just bag 'em, throw it, you can do it. Yeah. You know that you can maintain SATs. So what are you worried about? 

Erik: That's an important thing.

And actually that's a really important thing to remember as we talk about some of these things. Because if you can give, if you can ventilate your patient and oxygenate your patient, then [00:14:00] you should have a tremendous sense of security. Yes. And you should be relaxed and you just go for it. Just don't monkey around too long.

No. Just a number, 10 to 20 seconds. Yep. And then give Ventilate 'em again. Re and don't do the same thing. Change it a little bit. What do you mean? A lot of times Oh, if you miss, yeah. Oh yeah. I've seen some of my medical students and residents will do this is they'll go to innovate and they can't get it, and they do the exact same thing again.

Matt: Yeah. What's the definition of insanity? Exactly. So 

Erik: that's important to keep in mind. 

Matt: So what are some things that you would change? [00:14:30] So you go to intubate and 

Erik: I think that's exactly first of all, I think, yeah, I mean we, there's a lot of things to change, we'll talk about, I think a lot of the.

The airway management stuff, you can change. But I think what's more important right now, in my opinion, Matt, to talk about would be the assessment. 

Matt: Okay, let's 

Erik: do it. Because you know what the indications are. We talked about that, and it's complicated like we talked about. And so in that whole milieu of.

It's complication. You've gotta decide whether your patient fits in that bucket or not. And that's what airway assessment really is. And I, when I do an lp, for example, in the er, I spend [00:15:00] more time setting up that patient. The actual procedure only lasts, just a couple minutes. Yeah. But the setup is the key. And I think that's true for airway too. I think you wanna make your first attempt your best attempt. Yeah. So airway assessment is that first part. So what do you do when you, as, when you. You've decided this patient needs to be intubated.

I think what we're doing now is we're assessing our patient. Are they gonna be a difficult airway or not?

Matt: I think you can tell. I honestly now, I might get, you might whack me for this, but the malin whack you, you might whack me upside the head for this, but like mal and [00:15:30] potty so as a nurse, yeah.

When I worked pre-op Uhhuh in a surgery center, like the anesthesiologist always come in, Hey, open your mouth for you, Uhhuh, in my opinion as a pre-hospital provider. Yeah. If I have to take their air, just like you had that guy with, Hey, I've gotta intubate this guy. I don't have a choice here.

I've gotta get this airway. It doesn't matter what his mal body is. No, that's true. Or it doesn't matter what his lemons like. I've gotta get the airway. And you can look at him and just visually see, yeah okay, this guy's 500 pounds, he's got no neck. Yeah. That's gonna [00:16:00] be, he's very anterior or whatever.

Or a pediatric patient, 

Erik: right? Like 

Matt: I know they're gonna have a big floppy tongue. They got their big heads, all they're very anterior. Yeah, I know that's gonna be a difficult airway, when I go to intubate, just like we said at the beginning, I'm stacking the deck in my favor. I'm making sure my pediatric patient, I've got lots of padding under the shoulders.

For room for that big head. I'm putting 'em in that ear to sternal notch position positioning. Yes. 

Erik: That's part of, that's I would say the most important part. Airway management. A hundred percent is positioning. Yes, absolutely. 

Matt: I was trained to [00:16:30] innovate flat, and now we're talking about, raising the head of the bed, actually innovating.

At the head of the bed. That wasn't how I was trained. Yeah. But when you think about it, it's oh, that makes a whole lot more sense. No. That's doing those kind of things. 

Erik: No, it's true. I think there's a way to do it. It's changing and data's changing what we do.

Changing what I do. Yep. My setup is different. I think that you mentioned melon potty, the Lemon. There's so many different ways, but I think one of the things I like to do is to look at our anatomy.

Cause really what you're trying to do, I know if you're listening to this in an audio, you can't [00:17:00] see me, but, my trachea is if I was laying flat on our table, right?

My, my trachea is gonna be parallel to that table. So if I'm laying flat, my trach is gonna be in the horizontal plane. Now my airway, my oral axis is gonna be perpendicular to that.

So if I'm laying perfectly flat and my head is perfectly aligned, my neck is straight. This, it's gonna be about 

Matt: like a 90 degree angle.

And you put it up angle. Yeah, exactly. 

Erik: That's the beauty of the sniffing position, is you lift that chin and you try to get the chin to the level of the ella and the sternal notch. And the [00:17:30] traga, the here. To the same level that sniffing position, what it's doing is it's increasing the angle of your tracheal.

Axis. Yeah. And then you're decreasing the angle of your oral axis and you don't need to know Increasing, decreasing a, you're 

Matt: putting 'em more in line. Exactly. As opposed to that 90 degree hockey stick Yeah. That you're trying to overcome. Yep. With the bougie or the tube and you're keep hitting the veic.

Like, why isn't it going in? It's because of your positioning. If you would change it, whoop, that thing would probably swoop right in. 

Erik: Absolutely. And so I think that's really [00:18:00] what. Is going on with airway assessment, whether, whatever tool you're looking at there's some little things like mal and potty that can, but it's all really basically the same thing.

Because you've, and you've really got the laryngeal axis too, but to make it simple, I just look at oral axis and tracheal axis, right? You're trying to line those two things up. Now, if you have a patient in a c collar 

Matt: Yeah.

Erik: Different story. That's why it would be so foolish to go direct. 

Matt: Yes. 

Erik: In a patient with a c collar, you need to make that corner, you need a camera, a video assist. Yes. And so [00:18:30] using video in those situations, if you don't have video. You might wanna think long and hard about having your department spend the 3,500 bucks on a McGrath or whatever it might be, and 

Matt: the rigid stylets.

Those things are awesome. Oh, on a patient in a CCO video with rigid, that thing hooks that and poop. It just slides right in and it, but there's a technique to it. Yeah. You have to train on it. Or else you can do some damage.

But yeah, those things are really nice in those kind of airways.

Yeah. So when you're looking 

Erik: at your patient, there's things that, there's things that you can see to determine whether or not you're gonna have a difficult airway. [00:19:00] So one of the first things that I would do, and I. I like the lemon acronym, but but we don't need to do that. But is when I'm looking at my patient and I'm looking at the jaw.

The 3, 3 2 rule is, I think important. If you have them look, you open their mouth to do a malan potty and you're looking in the oral cavity and you can't see the U vva. Yeah. This might be difficult therapy. And then you go stick your fingers in the mouth and you can only get two fingers in the mouth instead of three.

That's gonna make this even more difficult. And then you stick with three fingers under the jaw and you're like, wow, this place has got a very short jaw. [00:19:30] Wow. We're gonna, this is a difficult airway. And they got such a big, thick neck. You don't even have your two fingers below.

The atoms apple to the base of the jaw. Yeah. So there are a lot of things that you can do to assess the airway. Or if you can't do those things, you're, you could be on your way to a very difficult intubation. In addition to that, patients with facial hair. A bearded patient.

Yep. You get, you get the. You The Duck dynasty guy or the Yep. Or the biker guy. Yeah. The

Matt: Big beard falls teeth. That's another issue. That's right. People got dentures in there. Yep. I've heard actually that [00:20:00] you now, they're saying keep the dentures in. When you go to intubate actually gives you something to support.

I don't know if That's 

Erik: right. Yeah. When you're bagging them Yeah. And preparing gives that oftentimes people will take them out too soon. Leave them in. Yeah. Until you're gonna intubate, then take 'em out. Oh. 

Matt: So that's what it was. Bagging you get a better seal, but when you go to intubate, take 'em out.

That makes sense. Yeah. And 

Erik: I would leave them in as long as possible. Yeah. And then be careful too with potentially like elderly folks that still have their teeth. They're more fragile and you can get airway obstruction with breaking teeth and being careful. 

Matt: Yeah. Remember it's not a rock bag.

It's so [00:20:30] funny, especially with firemen, you get these big, huge guys and they're trying to muscle like 

Erik: Yeah. 

Matt: It's a technique thing and you really shouldn't have to muscle it. 

Erik: Yeah, 

Matt: It's all about how you're, you get these, some of these anesthesiologists or little tiny females, they can go in, whoop.

And they see it perfectly. And then you get this six foot, 3, 250 pound fireman who's trying to wrench the face back. It's bro, it's all about technique. And you have to learn that technique. You have to practice that technique. It's a really, it's not a muscle thing. No. 

Erik: Yeah. We'll hit some of the difficult assessment airway stuff and we hit the [00:21:00] second, those populations in the second half of the podcast.

But I think that understanding that the assessment of your patient in determining whether or not it's gonna be difficult or not right, can really help you. Now I like to think of every airway is difficult. Before I intubate in the hospital, I mark out the anatomy on the neck. Oh, okay. 'cause you never know.

And so I would advise that. Mark it with a Sharpie. Yeah, a surgical pen. I'll just mark out the anatomy. Interesting. Look for that cricothyroid membrane. Yeah. So there's brainless if I have to. It's just one less thing to do 

when 

Matt: things get stressful. 

Erik: Yeah, 

Matt: [00:21:30] because I can tell you, and as like when you go to CRI somebody, it's I really hope I'm feeling the cricothyroid membrane.

Yeah. Because I'm super stressed right now and I don't really want to do this, but I know that I have to do it. Doing that assessment makes sense 

Erik: just. Writing it on there. Yeah. It just takes one thing that you don't have to do. I like that. Knock on wood. I haven't had to do it, but if I did, you've 

Matt: never had to crack somebody?

No. I haven't. Oh, I was like, surely you've, you 

Erik: probably won't, but you never know. You never know. 

Matt: It's in our department. It's when I did it years ago, I was like the only person that had done one in our department. Now, I bet there's a [00:22:00] dozen people that have done them. It's become more and more common, actually.

I find doing the surgical CRI easier than intubating somebody. It is pretty 

Erik: simple. 

Matt: It's pretty simple. You just, it can be 

Erik: tough. 

Matt: Sure. Like anything. Yeah. If they've got a lot of tissue you gotta cut down. But, usually in those situations, that's the last ditch effort. 

Erik: So there's a small percentage of the population too, that have this variant artery right down the middle.

Oh. 

Matt: Lovely. That right down the middle. Yeah. 

Erik: Oh, that's 

Matt: lovely. It's hit that thing, 

Erik: anatomic 

Matt: variant 

Erik: that you could hit. 

Matt: I, you never know. When I did mine, I we [00:22:30] got the suction and everything. We were getting ready to go, knew the guy knew there was an obstruction, like bagging was not working, nothing was getting through.

And so we had the suction ready and I go to cut and I'm cutting. And one of my guys, he's got turns the suction on and the battery suction. Oh no, I, there wasn't a tremendous amount of blood. There was a little bit of bleeding, we scrapped some towels. But you can, and 

Erik: it's, if you know what you're doing Yeah.

You can even feel it. You know where to where. Oh yeah. 

Matt: Luckily my patient had good anatomy and it was pretty easy to find. [00:23:00] And it was successful, we got it into everything. But yeah, the suction died, which was just one other level of stress that I didn't need at that moment. But that was fun.

That was interesting. So part two. So we talked about like indications assessment, super important. Obviously it's gotta be indicated. 

Yeah. You 

Matt: gotta do a good assessment on your patient to realize, but I think even if whether it's gonna be a difficult airway or not, we're still doing a lot of the same things.

Yep. To again, stack the deck in our favor to have that first pass success rate. 

Erik: Correct. Yeah. So the second half of our [00:23:30] podcast, we'll hit up some management pearls, and then we'll look at four different difficult patient populations to intubate. 

Matt: Let's do it. 

Erik: All right. Part two. Of our airway.

So we've talked about the, in indications Yep. Assessment, and then we get into airway assessment. Yep. And then you've, so you've, you need to intubate for a good reason. Yeah. And you've assessed your patient, what you're getting into. Now you're actually getting, you're getting it done.

So I think positioning would be the first thing I would want to talk about. [00:24:00] Actually maybe another thing actually, is making sure you got your tools. Yeah. There's a lot 

Matt: of stuff that's happening at the same time. 

Erik: There is.

Matt: So it is a, this is a team effort.

You in the er, it's not, you're not doing everything right. No. You've got, nurses or respiratory, or whoever's getting your equipment ready. You got somebody getting meds ready like me in the back of the ambulance, I've got at least one, if not two people on meds. I've got, if I'm getting the airway, I've got a partner who's getting all of my airway equipment ready.

But I think too, the other thing we need to look at is [00:24:30] what's the condition of our patient?

So we talked about assessment. One thing that we didn't talk about was what do their vitals look like? 

Erik: Yeah, good point. Is 

Matt: this an oxygenation issue or is this a ventilation issue?

Do I need to just throw a non-rebreather on this guy?

Or just a nasal cannula? Yeah, because he's breathing fine. Yep. But his SATs are low. Yeah. And then I want to do like a nitrogen washout, so the quicker you can get like a high flow nasal cannula on your patient and get that oxygen going and get that nitrogen washout going, the better you're setting yourself up for [00:25:00] success down the road.

Erik: Yep. That's a good point. And then 

Matt: vital signs too. 

Erik: Yep. 

Matt: Blood pressure, heart rate, you know what is their blood pressure crummy? 

Erik: Yep. Monitor tidal, all of these things. These are important. 

Matt: Yeah. 

Erik: And having 'em all set up and ready to go. 

Matt: Yeah. Having everything ready to go. Yeah. You're giving fluids.

Like I said, you got your airway guy, Uhhuh, he's got the appropriate size tube. He's got your bougie or your Bridget. He's got vo, he's got DL ready to go. He is got a backup. He's got all these things ready to go. Filter line end title. Yeah. [00:25:30] It's always funny, once you get that tube, you're, oh, I gotta get the filter line out, right?

Yeah. So it's really important to have good a good team with you, right? Yeah, that's right. You have capable people doing the meds. They're calling out. That's another thing is, hey, I'm gonna give, a hundred of ketamine and a hundred of sucks, or whatever the medication is, that you're using.

Calling that out is important. So it's okay, does that all sound right? Yeah. Because somebody says, I'm gonna get 500 of ketamine and a hundred. Wait a minute, that doesn't sound right. What's going on? That's 

Erik: good point. Yeah. That's [00:26:00] definitely, you got the understand the clinical context of your patient, right?

You got your materials all there. You've got your meds drawn up and ready to go. These are all things that we can discuss as part of management 

Matt: do you guys have a checklist in the er, like an actual checklist? 

Erik: No. Or is it, 

Matt: yeah. See, we actually created an actual checklist. 

Erik: That's smart.

Matt: Yeah. So that when it's laminated sheet, so like the captain or the officer drives somebody who's kinda standing back is he's standing back with the checklist okay, what's, I've gone in on innovations and they don't have the s SPO two on the [00:26:30] patient. 

Erik: Yeah. And 

Matt: they're about to push Yeah. Induction meds or paralytics, and it's whoa.

What's their sa what are they satting? 

Erik: Yeah. Oh. 

Matt: So do you have that on? Do you have all your equipment ready? Like you're saying, do we have an IV established? Have we figured out a weight? Yeah. Have we done the calculations on the drugs? All of that stuff should be done, 

Erik: On one hand in the er, I think that it's nice because it got an rt that comes in, rolls the ventilator in. Yeah. It's got all the airway equipment. Yeah. And then I've got my nurse team with the meds and then, getting this together. Patient's on the monitor. [00:27:00] Okay, Dr. We're ready to intubate. Yeah. And then I come in and we go, oh the king walks 

Matt: in. That must be nice.

Now you're get, you said the other day, you're working now at this freestanding and you're getting a little bit of, it's different. Yeah. Fuck. It's different because I've done this with pediatric patients with two other dudes in the back. 

Erik: Yeah. You're doing everything. That's all I get. Yeah. You're doing everything 

Matt: right.

Erik: There's a problem though. With it. I have found with what? I have to be very careful because when you're in a group with a lot of people on your team there's this thing called crowd bias. Sure. Where, [00:27:30] because there's so many people, everybody just assumes somebody did it. Oh, okay. So sometimes things don't get done.

The classic example of this would be somebody you're in an apartment complex, you hear somebody screaming because she's being abducted. Everybody hears the scream, but everybody thinks somebody's gonna clearly call 9 1 1 here. 

Matt: Yeah. 

Erik: Nobody calls. Yeah. So that's what can happen with crowd bias.

You can actually have people not do something that's pretty straightforward like SBO two. And just assume I, they did that. I don't need to dis my job. And the fog [00:28:00] of 

Matt: war, so to speak, that you're. It's two in the morning, you're on the side of the highway, major accident, and you're trying to wake up and now you're in go mode.

Yeah. Things can get missed. That's why we have that checklist. Somebody standing back going, do we have this, do we have this? All those, because the actual procedure, like you said in the first part is pretty quick. 

Erik: Yeah. 

Matt: It's the, all the stuff beforehand, the prep. You know that, that's the important step.

Positioning, assessment. Getting all your, all the other things. That's what's important. 

Erik: And I would say too that in the ER we have the benefit of a lot of practice. Every shift we're [00:28:30] intubating multiple people. Yeah. It's just a common thing that we do. Would you really intubate somebody every single shift you worked?

I would say most shifts on average. Intubate on average. Some. Some I've intubated multiple. Yeah. You can intubate three, four patients in a shift. Yeah. It depends too on how busy you are. Up and when I was working up in ou, a medical level one trauma center. 

Yeah. 

Erik: It's the only level one trauma center in the whole state.

Yeah. 

Erik: And I'm intubating multiple people every shift. 

Yeah. 

Erik: Dr. Ene trauma Bay two please, Dr. Ene trauma Bay two. And I walk in their patient's ready for me to intubate trauma teams there. And I just, I'm just there. [00:29:00] Airway That happens multiple times. Every shift. Yeah. And but anyway, my, but with all that practice, when you're intubating frequently, you get into a system.

Yep. 

Erik: And that system can help. You to develop a bit of almost like airway culture, complacency of people. Are you saying good thing? 'cause people do it so much, it's okay, we got this, we all have our rolls. It's kinda like a pit crew. Yeah. Yeah. You get you, those pit crews can change those tires and gas up that Formula One car. Pretty fast, right? Yeah. Because they do it so much and they practice and they have a system. 

Yeah. 

Erik: And that's what [00:29:30] we do. In the er. I think in the pre-hospital environment we're very good at airway, but we don't get a lot of the same reps, I would say a hundred percent depending on where you work.

Depending on where you work. Yeah. Yeah. And so anyway, but when you get a lot of reps for doing certain things, you get good at it. Oh, for sure. But you can become complacent too. Yep. And then it's oh man, I've never had to do this before because Bob did that every time. Bob's not here. I've never seen this 

Matt: tumor in their throat before.

Yeah. Whatever the case may be. Or you get a patient with Down Syndrome, and you're like, oh, I've never seen this before. That's right. This is gonna be a difficult deal. Be difficult 

Erik: their way. [00:30:00]

Matt: Yeah. So you gotta figure that out. Like you said at the beginning, the assessment portion. 

Erik: But positioning is important, and I think we'll talk about some of the unique positioning things with each of the, as we in a little bit here in just a few minutes.

But for now, I just try to align the tracheal axis with the oral axis. I think that positioning is huge. Yeah. And then once you've got your patient position properly you've got your. Video laryngoscope, all your equipment's ready, all your equipment's ready to go. You pick the right tube.

I for men, I usually use an eight, and for women a seven or [00:30:30] seven and a half, depending upon body size. You've got your, everything's all set up and ready. You've got your suction, you've got 

your, 

Erik: Your tube, whatever you use to secure the device on your patient. You've got all of everything's ready to go.

And for me, I like to have my backup stuff there too. You've got the bougie there if I need it. I've marked, like I talked about, so you go 

Matt: in with just the tube. Do you have the rigid stylet or do you just have the tube? Yeah, I use a stylet. Yeah. So the rigid, the real hard. Okay. No. Or just the regular style.

Erik: It depends. Like a video, like a, if I'm using the GDO scope in the er, which is what is most common in [00:31:00] the hospitals I work at, they have a a rigid stylet. Okay. That's mated to the ergonomics of the lydos. It's got that hockey 

Matt: stick. Yeah. Yeah. It's got that hyper angulated blade on the, your right.

Vo and yeah. 

Erik: If I'm going direct, I like the flexible stylet and I make my own hockey stick. In the way that I. I want it. Yeah. You don't use a 

Matt: bougie when you're doing dl? 

Erik: No. No. Okay. No, I don't. Yeah. That's my backup. Yeah. I have a stylet with my tube. But the agencies, not all of them, but the agencies [00:31:30] usually have bougie first.

Yeah. That's what we do. Yeah. Yeah, which is good. And then I think once, once you've got your laryngoscope ready to go and you've got your stuff, and then you're all set up we talked about this earlier and, hopefully you get the airway right away. You've got your Mac or your Miller, whatever you like to use.

Most people use a Miller. I'm sorry, A Mac. A Mac, yeah. Pediatrics of Miller. We'll talk about that later. But great visualization. And pass the tube. That direct, that visualization, whether [00:32:00] it's video or direct that is the most important thing. Oh, for sure. In the procedure itself.

For sure. And then get you, that's such a good feeling too. 

Matt: It is. When you see it and you watch the tube and the cuff go past, you're like, okay, good. Pressure's off now. We're good. 

Erik: Yeah. Still a little bit work to do. Sure. You gotta confirm it with you. You got, vapor in the tube. Your breath sounds.

End tidal is the systemic end. Tal, right? Yeah. Mainstay of, yep. And I, those things become even more important though, when you don't have visualizations. You got this big floppy epiglottis and you [00:32:30] know the airway's up there, or maybe you're chasing bubbles or something.

Yeah. 

Erik: You don't know for sure if you're in Yeah.

You've gotta confirm it. Yeah. Yeah. With those things you don't wanna. Tube, the goose. 

Matt: Yeah. And if you're, being a good partner, like you said, if you're the one setting up everything, have all that equipment ready. If I'm on the side of the patient, say you're getting the airway and I'm on the left side of the patient as you're going to intubate, I'm getting ears out immediately.

Yeah. So the second you say that tube's in, I'm, hopefully. Everything should just, like you said, like a pit crew, everybody knows what they're supposed to do. Yeah, exactly. When they're [00:33:00] supposed to do it, it makes it much smoother and much less stressful. 

Erik: And then we skipped over meds.

I think the reason why we typically will use an induction med is a patient it just, it puts them to sleep. It just, it's they're not consciously aware of what's going on. They're still breathing on their own. Yeah. A lot of the reflexes human are still there. Human, but you just, you're putting your patient to sleep.

You're in, it's an induction medication. 

Matt: And I think it's important to say you should never push a paralytic without pushing sedation. [00:33:30]

Erik: Correct. 

Matt: You should never, ever do that. And that is a bad thing that has happened where people get, that sucks your rock on board and it's like.

Oh, we forgot to push ketamine or whatever, accommodate 

Erik: whatever you used, accommodate ketamine ed. These are good induction meds, right? And then do that before the paralytic. 

Matt: Always sedate before you paralyze a patient. Yeah, that's, it. Sounds simple, but it has happened where that has not happened.

Erik: And succinylcholine vecuronium, macaron are some of the common paralytics that we use. But what do you [00:34:00] prefer? Oh, that's a good question. There's really, it depends on who I'm intubating. If it's a sepsis patient, I'm gonna avoid ate. If it's a, 

Matt: I like ketamine universally, it's I do too.

I go with ketamine. Yeah. That's just, those are our two choices to ketamine. Those are the only two things. And so most of the time I'm going right to ketamine because I can also use that for post innovation sedation. So it's just easier to have one vial. Yeah. For me.

Yeah. 

Erik: Yeah, I like sometimes I'll use Versed. But accommodate ketamine. But Ketamine what? Paralytic paralytic. I think rock is usually what [00:34:30] I reach for first. Yeah. I don't use sucks anymore. Yeah. And now that they have an antidote for those non depolarizing paralytics. I, it's a no brainer for me.

Yeah. 

Matt: Yeah. And in the hospital it's a little bit easier, obviously the concern, and you can go back and forth. People have their opinions. SO'S gonna wear off a little bit faster, but it has more contraindications to it. 

Erik: Yep. 

Matt: Where rock's gonna last a lot longer. You don't get the tube now you're bagging for a while, yeah. But yeah, I think most people probably prefer rock 

Erik: overp. Yep. Absolutely. So we got our patient intubated, post intubation care. If you have a ventilator, there's a whole [00:35:00] lecture for that, but but being aware of the peri intubation arrest potential. 

Matt: Yeah. Oh, so on the topic of peri innovation arrest and the met in the critical care world, we talked about this before, so if you have a patient that's, got a high shock index, they're in shock for whatever reason.

Trauma, sepsis, whatever the reason is. 

And they're already altered, right? They GCs is four or five, like we've talked about, a lot of times they will half the induction dose of whatever their induction meds are, half the ketamine dose, and then double the paralytic dose, which kind of makes sense.

Yep. What do you think of that as a No, it [00:35:30] doesn't. Medical director? 

Erik: If you have a again, I'm as a medical director, I'm gonna say always follow your protocols. 

Matt: Of course, yes. 

Erik: But 

Matt: don't double your paralytic dose without that being approved by your MedicalDirector. Yeah. 

Erik: But I think it's reasonable in certain populations to decrease that, that medication dose it.

Some of these geriatric patients don't need that full dose. They got that gorked out patient that's already halfway out anyway. Hypotensive. 

Matt: Yeah. 

Erik: Yeah. So you wanna be careful 

Matt: and resuscitate before you intubate. 

Erik: Yes. 

Matt: You should have good lines [00:36:00] going. Fluids, pressors. Yep. Don't go trying to intubate somebody with a heart rate of 50 and a blood pressure of 80.

Yeah. That's probably not gonna end well for you. You need to get some fluids on board. You need to try to get that heart rate up. Yeah. You need to get that pressure up because you go to try to tube that patient. Yep. They're probably gonna code on 

Erik: you now if you have a patient, you cannot ventilate or oxygenate.

Right then may change. But if you can ventilate and oxygenate your patient, there's really no reason to rush. The intubation shouldn't be called necessitate 

Matt: EMT rapid sequence. It should just be like we've actually changed it to just si [00:36:30] sequence intubation. 

Erik: I even used delayed sequence intubation. I know we talked about that recently on a podcast, or no, a webinar we did.

Yeah. With em S world.

And the delayed sequence innovation can be really nice. Yeah. Especially for that agitated patient. Yes. You know what? Let's consciously sedate this person. Calm them down. Yep. Then oxygenate them up. Yep. Get them, get their vitals there. Resuscitate 'em a little bit.

Yeah. Yeah. And then Intubates delayed. Yes. RSI. 

Matt: And I think you like I've seen it too. [00:37:00] Especially with pre-hospital providers that don't have a lot of experience, or they're a new paramedic and they're nervous. They push the induction meds and then they immediately push the paralytics. It's slow down.

Erik: Yep. 

Matt: Make sure everything is in place, just like we talked about in part one. Make sure you have all your equipment ready. You've done your nitrogen washout, you've got passive oxygenation going with a high flow nasal cannula. If that's what they need, right? 

Erik: Yep. 

Matt: You've got somebody on meds, you've got everything.

You've got your pressors ready in case every, you've got all this stuff ready to go. 

Erik: Yeah. And you 

Matt: push your induction meds, your whatever your protocol allows. [00:37:30] Yeah. Give it a minute. Yeah. Give it a minute to take effect, right? You'll be able to tell that patient's starting to relax, right?

Yeah. And then you push your paralytics and give that a minute. Don't just start shoving the Yeah. The laryngoscope in their mouth, right? Give the minutes, give the meds a minute to work. 

Erik: Yeah. 

Matt: Before you go into the procedure. Perfect. And I wanted to say, one of the things that I see a lot, especially with DL or with vo 

Erik: uhhuh, 

Matt: is people go way too deep initially.

It's like they're not looking as they're going in. You should be looking at your anatomy. Yeah. Okay. What am I seeing here? And we're [00:38:00] slowly working your way down until you get, you see the epiglottis, you put your blade in, into the veac where you need to be. You lift, okay? There's the vocal cords.

A lot of times I see people shove that. VL blade too deep. Yep. And then they go to intubate. And especially if they don't have the rigid stylet that bougie's going into the ocular and they're like, I can't make the corner. Come back a little bit. 

Erik: Exactly. Love it. 

Matt: Bring your blade back a little bit.

Yeah, I 

Erik: see 

Matt: that 

Erik: a lot. 

Matt: Yeah. Just bring it back 

Erik: just a smidge and, but 

Matt: practice 

Erik: helps 

Matt: that 

Erik: comes up. Yeah. 

Matt: Yeah, it comes right up. But that's where practice comes [00:38:30] in. So if you're working in an area unlike you, where you get a lot of reps on real patients, 

Erik: uhhuh, 

Matt: Most fire departments, I wouldn't say we're innovating somebody.

Maybe once a month, I would say. That's a pretty busy, yeah, you gotta get those mannequins out and practice difficult airways and different things. 

Erik: So for patient populations, let's talk a little bit about the trauma patient. I. The pediatric patient, the obese patient, and the geriatric patient.

Okay. 

Erik: Just briefly, so with a trauma patient we talked about this earlier, they're gonna be in a c collar. Yep. They're, you're not gonna have ideal [00:39:00] positioning. 

Matt: Doesn't mean you can't raise the head of the bed. 

Erik: No, it's true. You can raise the head of the bed, but you're not gonna, you're still gonna have an angle, not gonna be able to, yeah.

And you can take them out of the cco, follow your protocols, you can take them out life, the C collar, and then have somebody maintain traction. That's right. You can do that might help a little bit, but a video, you gotta go video and you can keep them in that cco. Yeah. And that's gonna be safer for the patient.

Matt: I would always do. You always suction first. 

Erik: Yeah. Absolutely. Yeah. That's another thing because in trauma patients, you can [00:39:30] oftentimes have a lot of contaminants. Yeah. Overdose patients too. That patient. You giving 'em Narcan, you better have that suction ready. That's right. And the salad technique, suction assisted.

The oral contaminants can really get in the way. And then before you start to use that tube. Suction. Yeah. Suction.

Matt: I have never been in an airway where there hasn't been. Something in the airway. Spit, vomit. You know something? There's always something in the airway, so why not? As soon as you go in there, give it a good, clear it out, clear out any fluid before you, [00:40:00] because you get one speck of something on that camera lens.

If you're using VL and you're done, obviously you can bring it out and wipe out, but why not just 

Erik: suction first? That's good. A couple other things with the trauma patient is sometimes, not only are they in a seaco sometimes you've gotta intubate 'em in non-ideal situations. Oh yeah.

And again, and this I think is really important with trauma, we always remember this. It might be easy to anchor on that airway. But in trauma situations, you've gotta take care of those other emergent conditions. First. [00:40:30] Airway may not be the most important thing to do. That's right. So don't forget that with the trauma patients take care 

Matt: of bleeding, stop bleeding first, right?

Yeah, 

Erik: exactly. You may need, if they've got a tension pneumo or whatever it might be, you may do, or flail chest or 

Yeah, 

Erik: you have hemothorax. There's a lot of things in addition to some of the other hemorrhage concerns with tourniquets and whatnot. The patient really. Doesn't need an airway.

As much as they need blood. 

Yeah. 

Erik: So don't delay anything that gets 'em the care they need. So that's, I think that's the big take home for [00:41:00] trauma patients. Yep. The other one I think that's worth talking about is pediatric patients. You've gone through your indications, you've gone through your assessment, you've gone through, you've got a pediatric airway.

It's gonna be difficult. Yep. Likely. Depending on the age, but some of the anatomic differences can be worth talking about. So little kiddos are gonna have a very high airway, their vocal cords can be very high. And interior. Interior. Yeah. Which makes that, that, that corner really tough to make.

Yeah. And then you got this patient, younger babies, they that head is huge relative to their body. You could [00:41:30] have a potential airway difficulty just by, based on their anatomy. Yeah. Bigger tongues, bigger upper glottis pad, the shoulders. Yep, that's right. Something under the shoulders.

Yep. Yep. Pad the shoulders. And I, like I said earlier, so you've got two things you wanna pay attention to the chin and the gella. That bone between your eyebrows, right? Above your nose. You want that chin and bel to always stay on the horizontal plane. And then we wanna try to get the.

Ear hole or the tra is to the level I like ear hole to the level of the sternal notch. You do that and [00:42:00] keeping the chin and glabella always parallel and horizontal to the horizontal plane. 

You're gonna put your patient in a great position and to do that, oftentimes with a pediatric airway, you've gotta have the towels under the shoulders.

So that's really, that's because everybody's anatomy's different. Yep. But by remembering that you're gonna put yourself in a good position lining up those axes like we talked about.

Matt: Yep. 

Erik: The other thing with pediatric airway too, I think this is really important, you actually said it earlier, is the clinical context.

These little tiny bodies.

They can rum fast. Oh yeah. [00:42:30] You may not have a lot of time. Yeah. They don't. Yeah. Compensate. You and I've got five liter of blood in our body. Yeah, that's right. They compensate. Yeah. You really well too. Yeah. And then, and you fall off the edge. Yeah. So being aware of that I think is really important.

That's a unique. A characteristic of the, and you have, 

Matt: so you have to be prepared for that, like we talked about, no matter every patient. 

Erik: Yep. 

Matt: You need to be prepared that the patient's gonna crash on you. Yep. You gotta have your meds ready, you gotta have your backup airway stuff ready. You gotta have all that stuff ready to go.

Yep. Regardless of trauma. Patient, pediatric, patient, doesn't matter. You gotta be ready for [00:43:00] what's the worst case scenario that could happen here. So that when, if. Hopefully it doesn't, but if it does happen, you're ready to go. 

Erik: Correct? Yeah. Yeah. The other thing I'd say about the pediatric airway real quick is a little kiddos.

There's, I like to use the Miller blade. I like to grab that big floppy epi, the glottis with the Miller. Pick everything up, pick that up. Pick everything up. Yeah. It's a straight blade. Yep. And then get in there and see directly visualization. Yep. Now you, there are some, I think there are some variations of video laryngoscope and whether or not they even offer a Miller.

[00:43:30] But it may not be as important with. Visual. A video laryngoscopy. But if you're doing direct in a kid, that's what I would do. I just, the way I do it. Is that Miller, and there's studies though, show no difference in airway success between the Mac and the Miller.

Matt: Like 

Erik: you 

Matt: said earlier, you do what you're comfortable with and what you practiced with. Yep. That's what you've practiced with. 

Erik: Yep. 

Matt: On your patients. And that's the key to it, is practice. 

Erik: I think the other thing that's interesting with pediatrics, I know as we move on here, we've got two more to talk about, but is.

The, with the other [00:44:00] populations, it's basically the same tube size, but with kids, little tiny infants, you're, you got a preemie that's, needs to be intubated because they didn't have the surfactant to, we gotta support their breathing and whatever, and open up those alveoli and you decide intubate, you're gonna be using a, a.

Tiny. A three. Tiny, or tiny little tube. 

Tiny, yeah. 

Erik: And in a tiny little airway. 

Yeah. 

Erik: And whereas if you got a 12-year-old Right. This might, you, might you get a five or a Yeah. Even a six potentially might be almost size two. Yeah. And so anyway, [00:44:30] whereas most adults, seven, seven and a half eight, right? For most adults,

I think that's important to know whether you're using an heavy or. Or a bras low, right? Whatever it is. Know your tube and the depth too, three times the size. That's right. Or whatever. You can, but you're honestly, you're gonna look, listen and feel and determine how the airway is right with the tube, right?

Matt: So trauma. Pediatric. Geriatric. 

Erik: Yeah, geriatric. So these are patients that are high risk for that per intubation arrest. That's right. And be careful with them. They've got a lot of [00:45:00] comorbidities. Yep. These are common intubation patients just because of the comorbidities. They don't have the compensation that the pediatric patients do.

Correct.

Matt: Or they might be on blood pressure meds or something that's not gonna, their heart rate's not gonna go up because their blood pressure starts dropping because they're on a beta blocker. 

Erik: S and then you may have trouble with the false teeth if you pull 'em out too fast. We talked about this earlier.

There's a lot of muscle atrophy in the facial muscles, right? You lose a lot of the foundation to what you're, placing your mask on the face, right? Yep. Keep the teeth in while you're bagging, take them out. [00:45:30] When you go to innovate, they might have lung issues, so 

Matt: ventilating, oxygenating might be an issue, right?

That's correct. I always, when I'm pre oxygenating. Throw in an NPA. 

Erik: Yeah. 

Matt: Like a lot of people obviously go for opa. Yeah. But I'll throw in an NPA and an OPA. Yeah. And leave that NPA and like we talked about too, get that high flow nasal cannon. If you get a nasal cannula on that nitrogen wash out takes two, three minutes.

Yeah. Definitely get that on there. It's gonna, it's gonna buy you some time. 

Erik: Yep. And you wanna consider too the medication dosage. We talked about this earlier with the halfway [00:46:00] gork patient. You might as well just give them half a dose. Yeah. Gram 

Matt: septic. Maybe just give her half the dose of ketamine and Yeah.

The paralytics. Yeah. Again, follow your protocols. 

Erik: Yep. Yep. So there's an ideal way to intubate with the geriatric population and remember tons of comorbidities. These folks too. Fragile teeth, easy for obstruction, knocking a tooth out, or, be careful with the cervical spine.

Yeah. Especially in a trauma situation. These folks are falls or whatever. Yeah, they can. And then I think that the last thing I would say [00:46:30] too is because they're on so many medications. 

Yeah.

Erik: Just. Be aware of the fact that these patients may be on meds that could counteract some of what you're trying to do.

Matt: Yeah, that's true. So that's a good point. 

Erik: Don't forget that grandma could actually be, have taken an in an accidental dose of her opiate and she 

Matt: Oh, I've had that before in nursing homes where, you go, you don't expect to be pushing Narcan on an 80-year-old. Yeah. But the nurse came in or whatever the case may be.

Yeah. Accidentally gave them the wrong meds. Yeah. And then you start looking and you're like, grandma's breathing three times a minute and has pinpoint [00:47:00] pupils. Let's try some Narcan. Yeah. If it's not that, it's not gonna hurt grandma, but if it is, and sure enough I have, I've had it where I give Narcan and all of a sudden grandma starts waking up and it's oh, okay.

Yeah. Now we don't have to tube. Alright. What was the last patient? 

Erik: I think the obese patient, yeah. I think that the 40% of our country is obese and 10% of our country is morbidly obese. Yeah. So this is a common patient that we will see Yeah. In the pre-hospital environment. Yeah. That is gonna present some difficulties.

For sure be if [00:47:30] you think about, just the BVM in an obese patient Yeah. You could have 40, 50 pounds of flesh Yes. On top of the lungs. Yeah. On top of that rib cage that you're trying to ventilate with a bag. Yeah. You combine that obese patient with a giant neck and a huge beard. Just the BVM itself is gonna be a challenge.

That's right. So I think that the obese patient's a huge challenge for us. Yeah. I think that if you lay a, an obese patient, flat. And try to intubate there. Yeah. Foolish. You've gotta ramp 'em. It's called [00:48:00] ramp, right? Yes. Yeah. And then you put 'em in the sniffing position and ramp 'em. 

Yep. 

Erik: You gotta do that 'cause it'll take some of the weight off the chest, make ventilation easier, ventilate 'em easier, and you'll align that airway.

Yeah. And again, we talked about airway assessment with the melon potty. Tons of soft tissue in their face and their oral cavity and their neck. 

Seen some of these patients with. Like a waist size neck, Oh yeah. They're huge. And that creates a lot of challenges for us.

Yep. And these patients need our help just as much as the other ones do. That's right. So we gotta know how to treat [00:48:30] 'em. 

Matt: It also brings up the ideal body weight versus actual body weight. That's right. What are you basing your medication dosages on? 

Erik: Yep. 

Matt: If you got somebody that's 400 pounds, you might not be dosing them at 400 pounds.

That's right. You probably shouldn't be dosing them at 400 pounds. 

Erik: Yeah. Sometimes the ideal body weight is how we dose these things. Some of them. Actually, you can't dose 'em that way because the it dissolves into the fat, the weight anyway, the point is. Obese patients. Huge challenge. Yeah.

Ramp 'em. They gotta, you gotta elevate the head of that 25 degrees. Yep. And use that when you're positioning your patient and it's [00:49:00] gonna be a difficult airway. So have everything set up with your backup. 

Yeah. 

Erik: Huge. 

Matt: And no. Again, like we talked about, if you can oxygenate. Don't be worried about the paralytic.

You know that if you don't get that tube on that difficulty airway, you can throw an IGEL in or OPA in and back. Yep. And you're gonna be okay. But take home points. Practice. If you are not getting reps regularly in the ER or whatever, you need to get those mannequins out. You need to practice and not just getting the airway, but.

The medication dosages ideal versus actual body weight. 

Erik: Yep. 

Matt: What equipment do I [00:49:30] need? The pressors that you're gonna be using, all that kind of stuff. You need to run through some scenarios. And be ready for that. That bad outcome if something goes wrong.

Erik: And that leads me to the one take home, I would say, is to stay humble.

Yes. Stay humble. Yeah. As soon as you get cocky air, yeah. The world will humble you. Being cocky isn't gonna help you or your patients. Just stay humble and practice like you said. That's good. See you in the next one. Safe [00:50:00] out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.