Intubation Difficulties

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I am currently in my second semester of Anesthesia school. We have been in the OR for about a month now and I am having a hard time with my intubations. I feel that I am so concerned with subluxing the jaw and not causing injury to the lips and teeth, that I am unable to visualize the cords. When I go in for the laryngoscopy I can see the Arytnoids and epiglottis but no cords. Any words of wisdom?

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Are you able to have somebody perform ELM for you on the hard to visualize airways? In addition, do you have access to a bougie? This can be quite helpful with these kinds of airways. (My humble non-anesthesia opinions.)

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I have never broken teeth or caused any injury to my patients over the years and I have had to "reef" on many to visualize. I would suggest a little more practice with the heads to build up your self confidence. It is very hard to injure a patient during intubation so calm down on your next attempt.

A couple of things might help...

1. Remember once you get your blade in lift straight up. It helps some people to put their thumb parallel on the handle (pointing up) and just pull it towards the ceiling. You cannot injure the teeth if your pulling straight up. Injury comes when you try to pull the handle back and up not just up.

2. On non trauma patients it is easier to tilt the head back, which I am sure you know. But a little trick for difficult patients is to let their head hang off the end of the bed with someone supporting their head. I have gotten really anterior patients this way.

3. Don't be ashamed to ask for cricoid pressure, it helps sometimes.

4. Finally, a real human is MUCH easier than the practice heads. If you can tube a head you can tube a person. I have a feeling that once you get your first tube you'll be fine.

Good luck,

Tripps

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First of all relax. Visualize the steps in your head several times a day. Focus on one thing-tubing the patient. Push aside any doubts you may have. Realize you have a job to do--and you can do it. Practice on the manikin and have your technique down. Be gentle --once you visualize the cords a few times you will begin to get a feel for the upward, lifting motion of the scope. Have confidence in your self...you can do this

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Specializes in IM/Critical Care/Cardiology.

first of all, congrats on your 2ND semester of Anesthesia school. It must be hard. I'm not that smart, but I can tell you that during ACLS training, I was the last person in my small group to demonstrate. I've never even tried this before. I kept missing and missing andmissing: the sweat just pouring down my face, but i was determined. (Even though this was the last class before break!) I, too thought of the teeth and your other concerns. I just kept readjusting and talked myself down and finally I saw that little tiny opening! I thought it was Christmas. And I'm sure everyone else EMT's, RN's, PA's, were happier than me so they could get out of their.

It was an embarrassment to myself but I finally did it, using only the straight #10, does that make sense? Others choose to use the curved device. You'll do it. And I wish you well in your career.

So embarrassed.........

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Wes - here's a cut and paste from one of my previous posts (July 2005) about missing an intubation ...

"Most students feel like the intubation "makes" the rest of the case. If you get it in the first time, you function with a sense of success and think more clearly. If you miss it, that's all you can think about at the beginning of the case (when A LOT needs to get done rather quickly) and it kind of ruins the rest of that case - which then leads you to second guess yourself on subsequent intubations that day.

Here's something I thought about any time I missed and it helped immensely! Intubating is a skill, just like IV's, A-line's, etc (albeit a more complex one). All it takes is repetition and some great clinicians to guide you and you'll get it eventually. So - when I miss on the first try, I step aside, focus on what the CRNA/MD does during their intubation and utilize whatever skill they showed on the next one. Whether it was getting a better sniffing position, changing the angle of my scope, switching blades or manipulating the cricoid before anyone else does to get a better view. All of these "pearls" helped tremedously in the beginning and kept my focus on the bigger picture of delivering anesthesia - not on how crappy my intubation was. This mindset eased my stress level tremedously going into the intubation and throughout the rest of the case (and you know how stressful you feel just starting out in clinical)."

Don't sweat the intubations - pretty soon you'll be sinkin' em like Tiger!

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Once you get into the vallecula, think "lift up to the left corner of the room" the trachea naturally deviates slightly to the left.

Dont worry, i used to cry in my car when i missed intubations as a student, we have all been there, and soon you will become skilled and wise with practice!!!!!

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Your problem sounds familiar :-) Ill begin with apologizing for my poor english :)

Prepare for the intubation by elevating the op table until you get a comfortable working position. Preoxygenate thoroughly - that will help you work a little more calmly without hurry.

Pile up the patiens pillow so it supports only the neck, letting the head of the patient tilt back slightly.

And when you insert the laryngoscope blade into the mouth, do it from the right, letting the laryngoscope blade "scoop away" the patients tongue to the left. An usual beginners fault is to insert the laryngoscope blade in the midline, leaving the tongue under the blade. This will make it much more difficult to create sufficient space for inspection and maneuvering the endotracheal tube.

So, be sure to get the tongue to the left (thats what the flange on the Macintosh blade is for) and Ill think you will do just fine.

/Anders K, Nurse Anesthetist, Sweden

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One thing I remember when I was learning intubations was I was worried about how long the pt was off the vent, alas, I lost my concentration and may have tried to get the pt intubated too fast. I'm sure the CRNA/MD has told you not to worry about the time. Of course, you too have to remind YOURSELF not to worry about it.

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Two additional suggestions to the other great ones.

1 I use a lot of external manipulation. Just use my right hand to manipulate the glottis into view. I may need the circulator to hold it there, while I insert the tube.

2. Once you see the arytenoids, advance the scope into the valluleca and the entire space seems to open up. (sorry for spelling errors)

If the patient is well oxygenated, ventilated and relaxed, you should have plenty of time to go slowly and identify the anatomy. Every one is a little bit different, which is what makes anesthesia exciting.

Let us know how you are doing.

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Thank you guys, It has been about 3 weeks since I posted this thread. Your tips have really helped. Still not a pro.

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Glad to know you're getting more confident. It's inspiring for SRNAs... and associated wanna-bes. (WHO could I POSSIBLY be thinking about??? :chair:)

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