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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, May 18, 2015

Airway Pearls from the CRASH Airway Course - Part 2

We are going to continuing with the Airway Pearls this week:
If you have not seen the last week's post on Airway Pearls, go through it first.

4 big airways pearls for this week are:

1) Positioning - Head lift 

I have emphasised enough about this last week with "horizontal ear to sternal notch" and "ramped up" position. If you are still don't get an optimal view despite doing these manoeuvres, one last thing which might help you before you move to your plan B is a "head lift" to visualize the cords. Here, with the tip of the laryngoscope blade sitting in the vallecula, you keep your right hand under the occiput and flex/extend the head. When you get an optimal view, fix the head at the same spot by supporting with an extra set of sheets.(see the image below)

    Head lift with your right hand to get an optimal view of the cords (Always use full PPE)
This is what I do to get an optimal view, 

1) Ear to Sternal Notch
2) Ramped up positioning
3) External Laryngeal Manipulation
4) Head Lift

and Move to plan B - if none of these work.

2) Make some space for yourself

When I was learning airway, there were many occasions when I got a chance to intubate and I failed to even insert the scope inside the mouth. And then my registrars/attendings/consultants used to come - do the procedure without a hitch and move on. I used to feel really embarrassed everytime this happened untill I realised that in some patients, with a huge chest wall or morbid obesity, it gets really difficult to insert the scope inside the mouth to start with. 

The best thing to do with them is, inserting the scope like we insert the Oropharyngeal Airway (see image "a" below), and once you enter inside the oral cavity, turn 90 degrees anticlockwise that brings you in the required position.(image b)

a - Inserting the scope in OPA manner and turning 
it in 90 degree anticlockwise direction
b- Scope position after 90 degrees anticlockwise rotation  
Another common issue is, not finding enough space to get the scope inside due to restricted mouth opening or a large tongue. This can be addressed by asking your assistant to pull the cheek on one side while you are inserting the laryngoscope inside the oral cavity. (see the image below)

                                                Asking your assistant to pull the cheek to the side
3) The ET Tube

A major pitfall while inserting the tube is, when we try and go straight into the mouth after visualising the cords. This blocks our own view of the cords and can lead to misplacement of the tube. This can be fixed by entering the mouth from the right side as depicted in the  image below. 
Trying to insert the tube "straight - in" & blocking your own
view of the cords (Wrong)
Inserting the tube from the right side, not
interfering with the view   (Right)                  
4) Bougie is your best friend!

Bougie must be available for every airway. Keep it in your airway kit - right next to you before taking the first attempt rather than asking for it after you have failed.

I have witnessed quite a few times "oesophageal intubations" with the bougie which makes no sense. The key points when using a bougie are:
  • Keeping the scope inside the mouth even after passing the bougie in - until you rail road the tube over the bougie. DO NOT TAKE THE SCOPE OUT and try to jam the bougie inside!
  • Learn how to differentiate between trachea and oesophagus with the bougie: Keep advancing the bougie inside gently and feel for the tracheal clicks --> If you hit the carina OR feel the tracheal clicks as you advance the bougie, then you are in the trachea. In contrast,  if don't feel any clicks or resistance and are able to advance the bougie almost completely inside, then you are in the GI tract.
Note: Be extremely gentle while advancing the bougie inside to avoid traumatising the airway.

Hope this was useful..Thanks!

Special note of thanks to Dr. Azhar and the authorities of Simulation Lab, Apollo Health City, Hyderabad


  1. Very useful tips indeed... Thanks for sharing

    1. I wud be more than happy if it helps you. 😊