Note to myself: In addition to reviewing EMCrit300, be sure and review again EMCrit 299 – Bougie Masterclass with George Kovacs
May 29, 2021 by Scott Weingart, MD FCCM
In this post I link to and excerpt from EMCrit 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle
June 16, 2021 by Scott Weingart, MD FCCM
Basically, I copied the complete show notes because doing so helps me to remember the material. Readers should go directly to the above link.
All that follows is from the reference: Scott Weingart, MD FCCM. EMCrit 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle. EMCrit Blog. Published on June 16, 2021. Accessed on June 29th 2021. Available at [https://emcrit.org/emcrit/airway-cqi/ ].
Create a Goal
Safe First Pass Success (sFPS)
*This is a link to a bonus EMCrit which further discusses DASH-1A.
An Airway Quality Assurance Program Improves First Pass Success without Desaturation
- What is good FPS
- Emerg Med Australas 2017;29:40
- Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.
- 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71
Creation of an Airway Lead
One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)
- Watches every intubation
- Conducts CQI / Reviews every Intubation that went Awry
- Lit Watch
Development of a Debrief Form
This form allowed a review and quality improvement process for every intubation.
Development of an Airway Database
If you are not measuring, I promise you, you are not doing well
A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.
Use of a Validated Failed Airway Algorithm
Development of an Airway Note
Key aspects of management: CL, story behind the airway
Standard Operating Procedure
No everyone cannot have their own way of doing things
Perfect Preox and Preintubation Optimization
We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized
Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.
VL for all First Passes
At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.
- Maximize FPS
- Maximize Learning
- Maximize Teamwork
- Maximize Reflection
Standard Geometry Video Laryngoscopy as Standard
Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.
Recordings and Videographic Review of All Intubations
Once the switch was made to video laryngoscopy for all intubations, mandatory recording of the intubations was required. This allowed a video review by the Airway Lead of all intubations.
Bougie* for all First Pass Except Hyperangulated Blade Intubations
After the publication of two studies documenting high FPS, we switched to bougie on first pass for every standard geometry blade intubation (2018 DOI: https://doi.org/10.1111/anae.14182; 2018 DOI: 10.1001/jama.2018.6496)
*It is critical to next review EMCrit 299 – Bougie Masterclass with George Kovacs
May 29, 2021 by Scott Weingart, MD FCCM
Change in Bougie Allowed use in All Intubations
A switch to a steerable tip, prebent bougie [Sharn Anesthesia Flexible Tip Bougie*] allowed the use of this airway adjunct even with hyperangulated blades. It also allowed placement in the glottis in patients with an anterior glottic opening.
*Here is the YouTube Video of The Sharn:
Airway Corner Session in Resident Conference
Key intubation recordings demonstrating errors or difficult conditions were shown in a monthly, 20-minute session. This allowed the entire program to benefit from rarely seen airway conditions and consistently noted errors in technique.
Teaching and Encouragement to Use Awake Intubation Techniques
Frees you from the dangers of 2nd pass decompensation
- EMCrit Podcast 247 – The Dissociated Awake Intubation with my buddy, Ketamine posted on May 16, 2019 by Dr. Scott Weingart.
- Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs
March 6, 2017 by George Kovacs [link is to the show notes and videos] from Dr. Scott Weingart