Massive Airway Contamination
Learn How to Master This Scary Airway Scenario
Patients requiring intubation in the Emergency Department are never “NPO after midnight.” This means that emergent airways are often massively “contaminated” with blood, vomit, and other secretions that obscure your view, increase intubation failure rate, and place your patient at risk of prolonged hypoxia and aspiration. The bottom line is blood and vomit pouring into the oro-pharynx your sick patient who needs a secure airway is just scary!
Fortunately the approach to massive airway contamination has also had a massive quality improvement overhaul, thanks to Jim Ducanto MD @. With his rethinking of how to clear a contaminated airway, his redesign of the suction catheter (and a new skill set to use it effectively), along with his construction of a creative SIM teaching tool to share this knowledge with others, Jim has literally built a solution to this problem from the ground up, and found a way to share that knowledge effectively with others. For me Jim’s approach has tamed the beast and transformed the way I approach one of the scariest problems an airway operator can face.
For some context let me share one of my first experiences with a massively contaminated airway. My patient with a life-threatening variceal bleed stopped protecting his airway and needed emergent intubation, but as soon as I put the Mac blade into the mouth, blood started to pour up into the oropharynx. As the cords disappeared from view I quickly grabbed the Yankauer suction as I was trained to do. With each clearing of the airway, I would remove the Yankauer and take another look, but no sooner was the Yankauer out of my hand than a new pool of blood would obscure my view. After several tries with this back and forth race, that useless Yankauer hit the floor and I thought seriously?!? There has to be a better way….
Since then I have used Jim’s approach multiple times in massively contaminated airway cases that seemed overwhelming with incredible success and feel it should be part of every Emergency Physician’s training. So let’s get started by doing a little myth-busting.
Myth #1 – You can’t use video laryngoscopy in a contaminated airway.
True you can’t shove a video laryngoscope into a pool of vomit and expect to see through it, but you can effectively remove that contamination ahead of the laryngoscope if you have the right technique and the right tools. Which takes us to myth number two.
Myth #2 – The Yankauer was designed to manage contaminated airways
I don’t know why I always assumed that the ubiquitous Yankauer was designed to manage the complications airway emergencies. Nope. Developed in 1907 by an otolaryngologist it was designed to remove secretions and blood from the oropharynx and surgical fields during procedures without damaging delicate mucosal tissue. It was never designed for the chunks of clot or vomit that can appear in your airway, and it was certainly never designed as a tool specifically to assist with securing the airway.
When it comes to clearing that massively contaminated airway lets use the right tool for the job:
Bigger is better…
Okay, it’s not just about how big it is, but how you use it…
That large bore suction catheter isn’t much better than that old Yankauer if you just dab around the oropharynx a couple of times and then pull it out. The Ducanto approach is what he calls Suction Assisted Laparoscopy Airway Decontamination or SALAD. The SALAD protocol provides a new set of airway skills that uses that large bore suction catheter in ways the Yankauer was never designed for; and it integrates those new skills beautifully into the mechanics of intubation with the video laryngoscope. In the video below these skills are presented in a step-wise fashion, and taught on the task trainer Jim designed to help translate these new skills into clinical practice with confidence:
Here is Jim sharing his approach to massive airway contamination that is overwhelming your ability to suction with some of our EM and Critical Care colleagues.
Jim sharing his skills with us and our ICU colleagues – Sept 2016
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