Tony Chipas, PhD, CRNA, regional director for clinical services at
Medstream Anesthesia Solutions, suggests adding a twelfth point to
Dr. Benumof's system: locating the cricothyroid membrane during the
pre-anesthesia exam instead of waiting until it's needed in the OR as
an emergency access point. "Often, we don't take the time to test the
patient," says Dr. Chipas, "to feel for crevices of the jaw, or to feel the
submandibular tissues that can cause problems."
3. Positioning can make all the difference. Getting a patient
into the ideal sniffing position before a procedure will save you from
having to reposition him for intubation should problems arise. A foam
rubber doughnut under the head might not provide the proper lift to
let you draw a straight line from the sternum to the tragus of the ear.
Instead, use pads or blankets (on an obese patient, you may need as
many as 5) to prop the head and shoulders.
"I call it the triangle of intubation — the pharyngeal, laryngeal and
oral access points," says Dr. Chipas. "That triangle is what you have to
overcome with a laryngoscope blade in order to visualize the trachea.
If the patient is in a good sniffing position, that triangle is very small,
and easier to navigate."
4. New and pricey isn't always better. Just because a piece of
equipment for treating a difficult airway is more expensive, doesn't
mean it's more effective. "The bougie is one of the most underrated
pieces of equipment we have," says Dr. Chipas. "It's just a piece of
plastic with a slight curve on one end, but you can use it to assist with
difficult intubations and avoid complications. In many cases the sim-
ple solution is the best solution. And the best instrument is the one
you know how to use."
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