Resuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success . Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could be blindly changed over a tube exchanger however it is quite easy to lose the airway completely during this process. We describe a potentially safer and more effective alternative.
Trick of the Trade
After a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide.
- Disposable bronchoscope
- Endotracheal tube
- 50 mL syringe
- Laryngoscope (video or direct)
- Trauma shears
Description of the Trick
- Insert a disposable bronchoscope through the airway port of the King airway
- Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina
- Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina
- Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway
- Insert the endotracheal tube over the “fiberbougie”
- Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords
- Confirm placement with capnography and/or with direct visualization and x-ray
Video Tutorial of the Fiberbougie Technique to Exchange a King Tube
- April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039. PMID 33684505
- Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation Cardiovascular Collapse in Critically Ill Patients: Insights from the INTUBE Study [published online ahead of print, 2022 May 10]. Am J Respir Crit Care Med. 2022. doi:10.1164/rccm.202111-2575OC. PMID 35536310
- Burns JB Jr, Branson R, Barnes SL, Tsuei BJ. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):92-95. doi:10.1017/s1049023x00007743. PMID 20405470
Ultrasound-guided IVs require hand-eye coordination and fine movements of probe in Goldilocks fashion. Apply too much pressure, and the vein in question is compressed. Slide a little to the right, and now it’s out of the window. Something that practitioners don’t think about is the tension from the cord. If left to its own devices, the cord will tug on the probe, making the probe harder to steer and handle, especially for those tiny veins.
Trick of the Trade: Reduce cord tension
Have the patient grasp the cord!
This makes them an active participant. Usually, if they are awake and good-humored, tell them “audience participation is required.” Doing so will give you enough slack to effectively visualize and troubleshoot the ultrasound-guided IV.
What if the patient is intubated, or altered, doesn’t quite grasp, or can’t handle the situation?
Tape the cord to the gurney side rail. Use a 2×2 gauze as a buffer between the tape and the rail so the tape doesn’t damage the cord itself.
Want to learn other tricks?
Read other articles in the Tricks of the Trade series.
Nasal congestion is a common symptom of upper respiratory tract infections, such as bronchiolitis, in newborns and infants. Because newborns are obligate nose breathers, any congestion presents a challenge during feeding and sleeping. These infants become frustrated when they cannot breathe while feeding and tend to have disturbed sleep when their nasal passages are occluded. This often leads to dehydration and irritability. Although the infant bulb syringe (above) can often alleviate the congestion, other commercial products may be able to more forcefully clean out the nasal mucus (e.g., NoseFrida, Bubzi Nasal Aspirator).
Trick of the Trade: DIY Nasal Snot Aspirator
In the Emergency Department, you may encounter families who may not have the resources to purchase or be aware of commercial aspiration devices for children. The concept behind our DIY Nasal Snot Aspirator is to allow the caregiver to suction the child’s nose using the negative pressure generated from the caregiver’s own mouth. The left video demonstrates how the NoseFrida works, and the right video demonstrates our DIY Nasal Snot Aspirator. Note that the specimen trap serves as the protective “filter”, or barrier, between the child’s suctioned mucus and the caregiver’s mouth. Thanks to Stephany Landry, RN, BSN for sharing this trick of the trade.
Equipment Needed: DIY nasal snot aspirator
- Left: Little Sucker Aspirator [Amazon]
- Middle: Short suction tubing
- Right: Mucous specimen trap, 40 cc [Amazon]
Description of the Trick
- Suction tubing: Attach one end to the Little Sucker Aspirator and the other end to the short connector port on the specimen trap.
- Instill some saline drops into the child’s nose.
- Insert the aspirator tip of your contraption into the child’s nostril.
- Have the caregiver suck out through the “straw” attached on top of the specimen trap.
The authors and ALiEM do not have any affiliation with any of these device companies.
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?
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 . 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 . 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 .
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.
- Materials needed
- Size 10.0 endotracheal tube (or the largest size you have)
- Suction tubing and canister
- Making the device
- Insert the rubber end of the suction tubing over the plastic endotracheal tube adaptor
- Attach suction tubing to the canister
- 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.
- 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