Perhaps nothing defines the critical care provider more than the ability to place some plastic between some vocal folds. And of all the topics in prehospital care, perhaps nothing is more controversial than paramedic intubation: should we, shouldn’t we, if we should do we use drugs to facilitate and if we do what drugs?…
I have followed the debate for some time, reading what literature I can and to date the only firm conclusion that I have come to is: Advanced airway management done poorly is worse than basic airway management done well (and airway research done poorly is worse than no research at all) However, today is not for teasing out the strands of this debate (mostly because I am post night shifts and am lucky if I have 2 neurons to rub together)
Today I would like to share a couple of excellent posts that are pertinent to anyone involved in airway management. First up, from Regionstraumapro.com is a succinct post on the horrors of intubating the patient in whom we suspect has a spinal injury.
Bottom line: From a mechanical standpoint, even in unstable spine models, the manoeuvre’s we use in preparation for intubation cause more movement of the spine than does the intubation procedure itself. The true number of spinal cord injuries actually (and provably) caused by intubation approaches zero. The literature suggests that video laryngoscopy results in less overall movement during intubation, but it doesn’t seem to have an impact on cord injury (you can’t get less than zero)
Laryngoscopy and intubation, by whatever means causes very little actual movement of the spinal column and does not result in paramedics paralysing hundreds of patients. I would say that my bottom line is: Airway comes first. If the patient needs and airway, provide one without fear of causing harm to the spinal cord. You will have enough to worry about without making the process more difficult with unfounded fear of crippling your patient.
Next up is a fascinating article from epmonthly.com with a take on two common laryngoscopy errors, one of which I had never considered before. One of the errors is the mistake of flexing the neck rather than elevating it, and Dr Levitan discusses the ramped position for obese patients. I think most of us are aware of the need for proper positioning to maximise our chances of first pass success. However the other issue I had never thought about was what eye one uses during laryngoscopy. We all have a dominant eye (mine is my right, like most people) and as we use only one eye during laryngoscopy, it is important to get the right one looking down the barrel. I have seen colleagues and friends (who wear corrective lenses) with what otherwise appears to be excellent technique struggle to intubate patients in whom I have had no issues. Whilst I initially just put this down to my overarching brilliance in all things, I wonder now whether this may have played a part in their difficulties.
So, maybe not everything airway, but a couple of clinical pearls that can have an immediate impact on your practice.