Managing the airway in prehospital and retrieval medicine is a challenge and has inspired many a discussion in many a setting. And anyone working in the area would appreciate the additional challenge when there’s lots of blood getting in the way. As a result everyone has tips and and tricks to try and manage things.
This is by no means the first time people have come up with an approach (or shared an approach) but in the spirit of wide-ranging discussion, here’s a suggestion from Dr Alan Garner recorded for posterity in video.
It runs for about 10 minutes and you’ll note that at the end there’s an update as the approach evolved.
All thoughts, feedback and experience very welcome.
The Collective 
Reblogged this on PHARM.
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kudos!
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Nice short video with some great points on the sump suction and slits in the cut tubing end. I like those. Also great tip on using ties onto a c-collar to provide traction on epistaxis balloons.
I would add that intubating through the LMA is ideal if you need to move to LMA.
Consider bougie first intubation, consider using suction as you go endotracheal tube (hooked up to a meconium aspirator and bronchoscopic elbow with a bougie or stylet loaded onto the tube).
Doing an awake dissociated intubation can also be helpful as you follow the bubbles and watch for moving cords to identify structures (along with epiglottoscopy first) in a soiled airway if your airway bleeding control/clearance is not enough. Topicalized anesthesia though is very difficult given the fluids in the airway.
If hypoxia is setting in, it is better to get a rapid surgical airway with a cuffed tube to oxygenate. Make sure each attempt that you try at definitive airway addresses the difficulty that you encountered with the previous attempt ie don’t do the same thing next time.
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Thanks Yen for the comment.
A couple of things that are not necessarily apparent from the video. Our approach is predicated on our standard airway algorithm which includes routine use of a bougie and finishes with a surgical airway (like many services standard algorithms).
We do now use the CMAC PM as our standard laryngoscope with Mac blades (we dont carry a D blade) but use direct vision as the standard approach and only look at the screen when the view is inadequate. This is a good approach in the heamorrhage context as getting blood on the lens is likely. VLs with standard Mac blades can always be used as direct laryngoscopes when this happens which is one of the reasons I am big fan of VLs with Mac blades (I have no disclosures to make regarding the CMAC although given how expenisve the devices are I should probable buy some shares in Storz).
Our approach is designed for prehospital use. All the equipment available to me was carried to the scene on my back or the back of my paramedic colleague. We dont have meconium aspirators or bronch elbows (doubt I could find these in my ED, and certainly not in a hurry). The approach is therefore designed to be simple and use minimal equipment.
I think the real messages are the sump suction and not getting fixated on the ETT as the only answer. In awake patients who sit forward and clear their own airway, then leaving them that way and transporting may well be the right move. A good pharyngeal seal with an LMA in the unconscious patient may provide a perfectly adequate airway for a short transport too. Like everything we do in the prehospital world this is a balance of risks.
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