Airway part 3

Ambulance CPDEndotracheal Intubation: 

Great discussion and review are ongoing as to whether Paramedics should have the skill set for performing ETI on patients. Several UK ambulance services have removed the ability to perform ETI. Reasons for this include low success rates, increased number of attempts required for successful intubation, and events where incorrect oesophageal intubation occurs and goes unnoticed by clinicians. 

Where clinicians are still able to use ETI, several mnemonics and practices from within the hospital environment can be used to aid the clinician. 

  • SOAP-ME – Can be used in preparation prior to attempting ETI ensuring all relevant equipment is available at hand: Suction, Oxygen, Airway equipment, Pharmacological agents (not likely in the Paramedic role), Monitoring Equipment (SOAP-ME). 
  • Levitan position – Placing the patient in the Levitan position (commonly seen as a ‘sniffing position’) and ramping their head and/or shoulders through using blankets/pillows/etc, will help optimise the view of the vocal cords when attempting ETI. 
  • BURP – Using a colleague to apply Backwards, Upwards, Right, Pressure (BURP) on the thyroid cartilage can help bring vocal cords into view during an ETI attempt. 
  • Sellick manoeuvre – The Sellick manoeuvre is where a colleague applies cricoid pressure to halt any vomit or secretions from the stomach. 
  • SALAD manoeuvre – Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) involves manoeuvring a suction catheter into the hypopharynx, whilst intubating. The suction catheter in place suctions any secretions or vomit coming from the oesophagus while the intubation attempt is made. 
  • LEMON – Can be used to help evaluate how difficult an ETI attempt will be: Look for obvious difficulties, Evaluate are the incisors able to fit 3 of the patients’ fingers indicating a good mouth opening, Mallampati score of initial difficult view (1 being simple, climbing to 4 being difficult), Obesity or Obstructions that may cause difficulty, Neck mobility for reviewing how well you can position the patient. 
  • DOPES – Can be used to interpret why an ETT is not working or ventilating well: Displacement, Obstruction, Pneumothorax, Equipment failure, Stacked breaths (is ventilation to vigorous/ineffective). 
  • DOTTS – Can be used to help resolve ETT issues: Disconnect patient from ventilator device, Oxygenate patient via BVM, Tube position and function review, Tweak ventilator device, Sonogram of tube placement (unlikely in pre-hospital environment).