Bimanual Visualized ELM

The following is a great example from Ricardo Urtubia showing how effective laryngeal manipulation can be in exposing the larynx. Note that in this case, once ELM is taken off, the laryngeal view is lost. This may be because the patient was not optimally positioned first with head elevation and ear to sternal notch positioning. Often, as mentioned above, ELM will seat the blade tip optimally within the valleculae to engage the hyoepiglottic ligament and lift the epiglottis indirectly and allow a good view without the need to continue to maintain ELM.

https://vimeo.com/178328945

[Update 2016-08-10] Ricardo further points out his opinion that ELM stabilizes the laryngeal complex to assist tube delivery into the trachea and thus should be maintained by an assistant.

On further thinking, this makes sense to train one’s assistant to practice this and do it routinely especially for those cases where ELM must be maintained for optimal laryngeal exposure and may be helpful for a difficult tube delivery (small spaces, larger ETT, hyperangulated indirect (“video laryngoscopic” or VL) approach etc).

The only downside of maintained ELM is when it is applied blindly (usually under direct laryngoscopy only (DL) circumstances), the exposure may become suboptimal or too much pressure is used and hampers tube delivery. VL/DL combination and trained/briefed assistants can avoid this issue.

 

Cadaver Study Novice Cricothyrotomy via Scalpel-Finger-Hook-Shiley vs. Melker vs. QuickTrach

Perioperative Medicine  |   August 2016

Emergency Cricothyrotomy Performed by Surgical Airway–naive Medical Personnel: A Randomized Crossover Study in Cadavers Comparing Three Commonly Used Techniques

Success rates (P = 0.025)

Surgical cricothyrotomy 95%,
QuickTrach 55%
Melker 50%
The majority of failures were due to cannula misplacement (15 of 20).
Few significant complications were found in successful procedures. No cadaver biometric parameters were correlated with success of the procedure.

Mean procedure time in successes (P < 0.001)

Surgical cricothyrotomy 94 ± 35 s
QuickTrach II 77 ± 34 s
Melker 149 ± 24 s .

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2528137

Heymans et al, Emerg Cric Naive Cadavers Three Techniques, Periop Med 2016

via and thanks to Mohammed Asiri

po: compact perpetual SALAD

Refinements on SALAD Sim

#CreativeThinking

A po … moves thinking forward … new ideas or solutions … lateral thinking technique … an extraction from … hypothesis, suppose, possible and poetry

source: Wikipedia

No space intubations


Originally posted in my Facebook community page #TBayAirBasedRounds
More to add regarding bougie for this too

Optimizing position

Right paraglossal straight blade

VL but minimize hyperangulated approach and hyperangulated styletting/bougie

Scope via SGA

Bougie via rigid suction (HT @jducanto see below) or VL/IL channel or CMAC left side channel

Surgical is your last resort (actually ECMO is?)