About Brenda Sokup, DO

Chief Resident, PGY3
Coney Island Emergency Medicine Residency

Trick of Trade: Large-Bore Endotracheal Tube To Suction the Occluded Airway

The paramedics just arrived with a new patient to the resuscitation room. You find an altered patient actively vomiting bloody vomitus and food particles. You prepare for a difficult airway. You prepare 2 Yankauer suction catheters, but you are still worried that the food particles may clog up the catheters. Is there a better alternative?

Background

Up to 44% of emergent intubations are complicated by blood, vomit, or food particles in the airway. It has been shown that contaminated airways may lead to multiple intubation attempts and are associated with poor outcomes, such as peri-intubation cardiac arrest [1, 2].

The Yankauer suction catheter is the most commonly available tool in the Emergency Department to remove foreign particles, but performs poorly when compared to larger-bore catheters [3]. The Yankauer was made initially for surgical field management, with small holes at the tip to gently remove (or become clogged with) debris without damaging tissue. Some standard Yankauer designs have a built-in safety vent hole on the shaft, which if unoccluded, renders the device virtually useless [2]. This protective equipment design does not offer maximum help during emergent large-volume regurgitation dirty airway management.

Alternatively, there is the DuCanto suction catheter. It is a specialized and more expensive large-bore version of the Yankauer; however, it is not as readily available and more expensive [1].

Trick of the Trade: Use a large-bore endotracheal tube as a rigid suction catheter

A large-bore, such as a size 10.0, endotracheal tube can serve as a rigid suction catheter. Note the diameter sizes of the Yankauer, DuCanto, and 10.0 endotracheal tube below.

Suction devices (inner diameter):
**Yankauer** (3.56 mm), **DuCanto** (6.6 mm), **10.0 endotracheal tube** (10 mm)

Materials needed
1. Size 10.0 endotracheal tube (or the largest size you have)
2. Suction tubing and canister

Making the device
1. Insert the rubber end of the suction tubing over the plastic endotracheal tube adaptor
2. Attach suction tubing to the canister
3. Turn suction on

Video Demonstration: Yankauer vs Large-Bore Endotracheal Tube

Editorial Note: If the rigidity of the catheter is less important, you can also insert the soft suction tubing directly into the airway to remove contents.

Read other Tricks of the Trade posts on ALiEM.

References:

Nikolla DA, Heslin A, King B, Carlson JN. Comparison of suction rates between a standard Yankauer and make-shift large bore suction catheters using a meconium aspirator and various sized endotracheal tubes. J Clin Anesth. 2021 Sep;72:110262. doi: 10.1016/j.jclinane.2021.110262. PMID 33839435
Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-754.e2. doi:10.1016/j.annemergmed.2012.04.005. PMID 22542734
Andreae MC, Cox RD, Shy BD, et al. 319 Yankauer Outperformed by Alternative Suction Devices in Evacuation of Simulated Emesis.” Ann Emerg Med. 68(4), S123 [research abstract] doi: 10.1016/j.annemergmed.2016.08.335

By Brenda Sokup, DO|2021-10-29T19:15:35-07:00Oct 31, 2021|Critical Care/ Resus, Tricks of the Trade|

IDEA Series: DIY Suture Kit Station

In medical training there is a lack of simulation based activities including procedural labs. Suturing is a critical skill for trainees to master in the emergency department. However, supervised practice is needed prior to suturing a real patient for the first time. This innovation allows early trainees to master suturing while on shift, using easy to find materials, which increases procedural competency and confidence. This activity allows the teacher to assess and correct the trainees procedural skills prior to attempting to suture a real patient.

Name of innovation

This Do-It-Yourself Suture Kit Station incorporates easy to find materials available in every emergency department, allowing early trainees to master suturing prior to suturing real patients.

Learners targeted

Medical students and early trainees who need suture practice

General group size

One-on-one student training is ideal, but can have multiple students who can practice using multiple suturing stations
If teacher unable to instruct while on shift, trainees can be shown a suture training video and practice alongside the video

Materials needed

Blue chuck pad
Paper/cloth tape
Scalpel
Suture material
Suture kit

More detailed description of the activity and how it was run

Make the DIY Suture Kit Station (see above video):
- Place a thick chuck pad on a flat sturdy surface.
- Apply cloth tape to the entire surface of the chuck, and tape over the chuck. This is now the suturing pad.
- Use a scalpel to make an incision to the pad.
- Use the back blunt end of the scalpel to ‘fluff’ up incision edges to make laceration.
Use a laceration repair kit and suture to close the laceration.
Instruct the trainee on proper suturing technique on the suture station (or show a suture training video)
Have the trainee continue practicing until adequate comfort and proficiency level is achieved
Suture real patient!

Lessons learned, especially with regard to increasing resident and program buy in

Procedural skills require much repetition to gain proficiency. This is best done with video tutorials, supervision, and deliberate practice.
Practicing in a simulated environment greatly improves skill and confidence in real clinical practice.

Educational theory behind the innovation including specifics/styles of teaching involved

Simulation practice increases procedural competency.
Practicing on shift allows trainees to reach the number of repetitions required to gain mastery in suturing, Routt [1] showed that the number of repetitions required to gain proficiency was 41 times.
Competency in suturing is required even when cases are low. Wongkietachorn et al. demonstrated that tutoring suturing improves the trainees’ skillset. A practice suture kit helps improve retention for real-life scenarios [2].

Pearls

This DIY suture pad station technique is easily available and inexpensive.
To improve suturing techniques and enhance skill retention, medical students and early trainees need to learn with guided supervision on simulated task trainers.

References

Routt E, Mansouri Y, de Moll EH, Bernstein DM, Bernardo SG, Levitt J. Teaching the Simple Suture to Medical Students for Long-term Retention of Skill. JAMA Dermatol. 2015 Jul;151(7):761-5. doi: 10.1001/jamadermatol.2015.118. PMID: 25785695.
Wongkietkachorn A, Rhunsiri P, Boonyawong P, Lawanprasert A, Tantiphlachiva K. Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases. J Surg Educ. 2016 May-Jun;73(3):524-8. doi: 10.1016/j.jsurg.2015.12.004. Epub 2016 Feb 20. PMID: 26907573.

By Brenda Sokup, DO|2021-10-08T10:19:05-07:00Oct 15, 2021|IDEA series, Trauma|