In EMCrit Podcast 117 – Everyday Emergency Kits [link to the podcast and shownotes] with Keith Conover February 10, 2014 is, as are all of the EMCrit podcasts, is outstanding and should be carefully listened to.
The part that I found most helpful was the discussion that reminds us of the usefulness of digital intubation.
Here are some YouTube videos on Digital Intubation and some additional resources after that.
The following is a link from Podcast 117 to the crashingpatient.com
from Rich Levitan’s Site (palpation of the epiglottis and posterior cartilages by the operator) A tracheal tube can also be placed with direct palpation of the epiglottis or larynx. It is easiest in patients with no teeth and a short distance from the mouth to the larynx. Children and edentulous adults are ideal for this procedure. It should not be attempted unless the patient is in cardiac arrest, is pharmacologically paralyzed, or for some other reason is not capable of biting. A stylet is useful for pre-molding the tube and stylet into a large arc, beginning at the middle of the tube and extending to the tip. The stylet should be well lubricated within the tracheal tube to facilitate removal. The procedure is most easily performed from the patients left side (assuming operator is right-hand dominant). Head extension lengthens the distance from the mouth to the trachea and should be avoided. Head and neck flexion may be beneficial, as long as mouth opening is not restricted. Tongue traction may permit further advancement of the fingers. The index and long fingers of the operators left hand are slid over the surface of the tongue until the tip of the epiglottis or the posterior cartilages of the larynx is appreciated. The right hand is then used to rotate the pre-molded tracheal tube and stylet downward between the fingers of the left hand. The fingertips help direct the tip anteriorly into the larynx. While the left hand stabilizes the tube, the stylet is withdrawn and the tube advanced into the trachea to the proper depth. In order to obtain proficiency with digital intubation, the clinician must have a good appreciation of what the epiglottis feels like while wearing a latex glove. Being able to palpate the posterior cartilages of the larynx can guide correct placement. Appreciating the feel of the epiglottis or being able to reach the posterior cartilages is quite difficult in many adult patients, especially those with prominent upper dentition. Conversely, this is not the case in small children. In practice, digital intubation is rarely used. Potentially in situations of massive bleeding (or other fluids) it theoretically has a role when direct laryngoscopy visualization or other imaging based techniques are impossible.
And I’ve copied the above post:
Blind Digital Intubation
- digital intubation allows intubation to be performed without a laryngoscope or a view of the larynx
- may be performed with or without a bougie
- Cramped environment (e.g. patient trapped in vehicle)
- Copious oral fluids (e.g. large amount of blood or vomitus in oral cavity, obscuring visualization with a laryngoscope)
- Inability to visualize vocal cords with laryngoscope
- Severe head/ neck trauma requiring immobilization of cervical spine
DESCRIPTION OF PROCEDURE
Blind digital intubation without a bougie
- After the epiglottis is identified by palpating it with the long finger of the left hand, the bougie is threaded through the glottis and advanced into the trachea. Tracheal clicking elicits tactile vibrations, which confirm tracheal placement of the bougie.
- The bougie is withdrawn slightly so that the 25-cm mark is at the corner of the lip. The endotracheal tube is threaded over the bougie while the bougie is stabilized in place.
- With the bougie held in place, the endotracheal tube is turned a quarter turn to the left and then advanced to an appropriate depth.
- The tube is held in place while the bougie is withdrawn. Tracheal intubation is then confirmed using capnography or an esophageal detector device.
- Fast (in experienced hands)
- No requirement for optimal positioning
- Minimal c-spine movement for trauma patients
- Ideal for those predicted to be difficult airway (eg. underbite, short neck, obese)
- Can be used if copious secretions/blood in airway and cannot visualize landmarks
- Requires training (cadaver or sim lab)
- Risks operator trauma from patient’s teeth
- Airway trauma
- Patient must be paralyzed or comatose/dead
- Benefits operators with long, slender fingers
References and Links
- Hardwick WC, Bluhm D. Digital intubation. J Emerg Med. 1984;1(4):317-20. PubMed PMID: 6501845.
- Rich JM. Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proc (Bayl Univ Med Cent). 2008 Oct;21(4):397-9. PMCID: PMC2566913
- Stewart RD. Tactile orotracheal intubation. Ann Emerg Med. 1984 Mar;13(3):175-8. PubMed PMID: 6696305.
- Vacanti CA, Roberts JT. Blind oral intubation: the development and efficacy of a new approach. J Clin Anesth. 1992 Sep-Oct;4(5):399-401. PubMed PMID: 1389195.
- Young SE, Miller MA, Crystal CS, Skinner C, Coon TP. Is digital intubation an option for emergency physicians in definitive airway management? Am J Emerg Med. 2006 Oct;24(6):729-32. PubMed PMID: 16984845.
FOAM and web resources