Ch. 13: Direct Laryngoscopy

Question 1

The Basics

Answer 1

• Create a direct line of site
• Tongue is biggest impediment
• Curved Macintosh blade
  
  • vertical flange displaces tongue left
  • Knob on end enters vallecula pushes hypoepiglttic ligament making the epiglottis elevate!!
• Miller blade has smaller vertical component.
  
  • blade goes under epiglottis
  • Better for smaller mouth opening
  • Less tongue control

Question 2

Anatomy

Answer 2

• Epiglottis
• Posterior arytenoid cartilages
• Interarytenoid notch
• Vocal cords

Nearly 100% when cords fully seen.

Can still be accomplished w bougie if only cartilages are seen.

If epiglottis not seen then no chance.

Question 3

Preparation

Answer 3

• IV and monitors. Saturation and vitals.
• All medications
• Laryngoscope and a backup
• 10 cc syringe and lubrication
• Suction
• Bougie
• ETT

Assistant: Hold head, Cricoid, Retract mouth.

Question 4

Assessment

Answer 4

• LEMON-Mallampati
  
  • Look around-eyeball
  • Eval 332 distances. Short madible or neck
  • Mallampati 1 best to 4 worst. No uvula visible
  • Obesity/obstruction
  • Neck mobility
• Curved blade controls tongue better

Question 5

Handling the Laryngoscope

Answer 5

• Hold the blade low. From shoulder. Elbow low.
• Bed up
• No stooping

Question 6

Positioning

Critical!!

Answer 6

• Creat sniffing position.
• Lower neck flexed forward. Upper extended.
• Ear hold to neck hold.
• In normal people 4cm head pad
• In obese build a ramp.
• Have assistant ready to place pads.

Question 7

Standard Laryngoscopy

Answer 7

• Insert blade on the right.
• Sweep tongue to the left.
• Find epiglottis
• Hyoepiglottic ligament pressed by tip of curved blade
  
  • OR epiglottis lifted by tip of Miller (straight) blade
• See arytenoid cartilages and notch.
• Glottis always anterior (above) this.
• See vocal cords if possible. Not necessary.

Question 8

Retromolar straight blade technique

Answer 8

• Prominent incissors, tongue or limited mouth opening
• Scoot Miller on far right to tongue tonsil border.
• Rotate so the tip heads midline.
• See epiglottis and lift it.
• Assistant pulls right side of mouth.
• Use a bougie to get between cords.

Question 9

Blind Instertion with Straight (Miller) blade

Answer 9

• Plan is get Miller blade into esophagus then pull back.
• Gently pass Miller blade along the right side pretty far.
• DO NOT FORCE.
• Then look and pull back while lifting until glottis DROPS into view.

Question 10

Getting the ETT into the tracha

Answer 10

• If introduced down the center the ETT can block vision.
• Come from the right side
• Hockey stick the end of the tube with stylet.
• Sneak it in low and at the last second rotate counterclockwise to make the end of the stick raise up into the glottis.

Question 11

TroubleShooting

Answer 11

• Paralyze
• External Manipulation: Intubater should do it with right hand till optimal view then have assistant maintain.
• Introducer: Best help when epigiglottis seen but cartilages and cord are not.
  
  • Place a bend in the last 1/2 inch.
  • Can feel tip ride over tracheal rings
  • Stops about 40cm. Won’t stop in esophagus.
  • Assistant loads ETT.
  • Rotate left once past epiglottis

Question 12

Failed Attempt

Answer 12

• Bag and oxygenate the patient
• Is positioning optimal. Perhaps life head with right hand.
• Change blades?
• Use paralysis?
• Maybe redose the succ (keep atropine close)
• External Laryngeal manipulation?
• Call for help.
• Use Video Laryngoscope?

Question 13

Confirm Proper Placement

Answer 13

• Color CO2 detector Yellow Yes. Purple is piss poor.
  
  • Rarely can get CO2 from stomach but fades in a few breaths.
• Waveform Capnography is best during arrest. Should have square wave.
• If not perfusing then waveform may not even detect.
• Can use a suction device to detect esophageal intubation.