KINGVISION (videolaryngoscope) – tips & tricks


A newish tool for us here in the prehospital world, video laryngoscopy (VL), brought to us here in BC via the King Vision (KV) device.kv

But why use VL? As many of the old guard often remind me… ‘just learn to #$%^ intubate (DL) and you won’t need that fancy new thang” …Sigh… after seeing many patents brought emergently into the ED without airways protected due to repeatedly failed DL attempts, yet the VL remains in its packaging…..well…… we can’t emphasize enough the value-added-ness of this new tool to your airway intervention repertoire.

old-cartoon-medicWe hope to introduce some of the benefits of this new tool, some challenges we have encountered with prehospital intubations (n=18 …1 today) here at RSM using the King Vision… & just maybe… there’s something in here for the old skool-ers.

As with all new tools comes new decision making models and metrics for analysis, king-vision-flathowever we will speak to the technical applicational challenges we have encountered. One key early challenge we faced with the KV was the resistance to lay the device flat onto the chest when placing the blade into the mouth. It was counterintuitive to lose your view of the screen at such an early phase of the airway manoeuvre (where traditionally one would be highly anticipating any view during DL). However, once you expected it (loss of camera view), one could redirect their attention to blade placement in the mouth, displacement of the tongue and then refocus ones attention back to the screen. Once the airway structures come into view remember you are flying a plane (back stick = up view), too commonly practitioners want to lift the handle as one would during traditional DL (leading to occlusion / worse optics). Subtle backwards tilt of the handle will change view as does left and right angle of the wrist. Subtle.

kingvisionbladesSecondly was the choice of channeled/non channeled blades. Initially ETT #7 and larger were difficult (almost impossible) to free (dry plastic on dry plastic = stuck) from the channeled blade had you not pre lubed the exterior of the ETT, so we switched to non channeled blades. However we found it difficult to direct a bougie through the cords without the aid of directional feed/bend from the channeled blade. We abandoned this approach.

Another challenge was that we experienced significant hang up of the ETT bevel on the arytenoids. Solved only by full twisting the tube 180 degrees after being freed from the channelled blade. This rotation allows the bevel to roll anteriorly and pass through the undamaged cords into the trachea. All other methods seemed to inflict some level of trauma to the arytenoid structure. More on this shortly.

Our solution that has brought is the most success (n=12 1st pass success), lightly lubed & pre tied ETT with bougie not loaded into a channeled blade.

Procedure. Introduce KingVision to airway and obtain best view. Feed bougie along channel. Pass bougie through cords. Slip bougie out of channel, leave KingVision in situ for best view. ‘Railroad’ tube of choice (<#8) into view along bougie. Roll rotate ETT 180 degrees to allow bevel to free from posterior airway structures into trachea without force nor damage to arytenoids. Secure ETT as per recommended approaches.
This combination allowed us the most successful parameters. Stacking all the odds in our favour, bougie to pass through cords, then a visualized roll advancement of the ETT into place using ETT markers for airway depth.

So what about soiled or fluid airway you say….well….we found that there is a coating on the screen of the blades that clears somewhat independently once it has been dunked in airway secretions/vomitus…and that with a little assistance from the yankauer tip suction whilst still in the airway, the screen regained its clarity. The inherent heat from the bulb quickly clears residual fogging. And recent adaptations of suction hose into channelled blade during advancement has brought excellent success to the heavily soiled airway…(more to follow)…

Another exceptional piece with using the King Vision is from the educational perspective. Now the new user can be coached through the visualization and airway capturing process in the pre hospital environment. Others practitioners can simultaneouly follow along with the airway manoeuvre from a distance and augment their own understanding of the process and procedure. As demonstrated here with the King Vision & Bougie pass to capture an airway in the spontaneously respirating pt.

King Vision Bougie pass from tyson lehmann on Vimeo.

Another great external review of the KingVision from the folks at EMCRIT can be found here.

Accidental Hypothermia – new and exciting from Dr Doug Brown

Dr Doug Brown has recently published in the NEJM and addresses the prehospital management of Accidental Hypothermia and how it relates to those who also practice in the backcountry.

Dr Doug Brown’s website linking to his research and paper published in the NEJM.
http://drdougbrown.ca/

Thanks Dr Brown, we appreciate your work and the support of those practicing outside.

Jiro Dreams of Sushi…an ember for the prehospital Shokunin

Jiro dreams of sushi, and in doing so finds us the essence of what it is… to be our best.

This month at rightseatmedicine we take a journey with Jiro Ono, and perhaps,  a glimpse of what it is like to be a master. Like Yoda, but real. And how we can be better at what we do and most importantly, how we view ourselves amidst our craft.

The concept of repetition, forward vision, the pursuit of mastery; all based on a foundation of humility, hard work, self reflection and a relentless dedication to task, as Jiro suggests, a ‘yearning to achieve more’.

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Exercise Associated Hyponatremia – stop the NS

Unable to put a finger on, or differentiate your young healthy patients first time seizure activity? The absence of trauma, infection, stroke, any pertinent historical findings,thCAIST0VW heat/altitude illness or other pharmacological based explanation leading you toward a primary diagnosis of neoplasm or some other insidious intracranial nasty?

As the summer and warmer months are upon us, the consideration of Exercise Associated Hyponatremia (EAH) is warranted in these individuals.

Wilderness Medical Society Practice Guidelines for the Ttreatment of Exercise Associated Hyponatremia are representative of “…the great strides that are taking place in an effort to prevent what is now recognized as a leading cause of preventable mobidity and mortality in endurance activities throughout the world“.

How does this affect me as a pre hospital practioner you ask? We here at rightseatmedicine have encountered a small cohort of patients in the Lower Mainland region of BC presenting with exercise associated hyponatremia.

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Spinal Immobilization & ice cream – why cant we stop ourselves

A bowl of ice-cream…spinal immobilizing our patients…why can we not stop ourselves; and often our partners, from indulging.images

In light of the recent avalanche of discussion surrounding spinal immobilization in the prehospital environment, presented within this post you will find;

  • the original JEMS article that piqued our interest here at rightseatmedicine,
  • the new and exciting publication by the Wilderness Medical Society for Spine Immobilization in Austere Environments,
  • a video-link courtesy of Gallatin County who have recently adopted an adjusted spine immobilization protocol, and
  • numerous other immobilizing menu items that are delicious food for thought.

Please enjoy.

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Capnography – ETCO2 monitoring and the way forward

Capnography now readily available to most paramedics and should be the prehospital standard of care for confirmation and continuous monitoring of intubation, as well as for monitoring ventilation and perfusion in any respiratory pt encountered. Additionally, it should see increasing use in the monitoring of any unstable patient of any aetiology, as well as optimizing trending within your perfusion assessment.images

Traditionally (here in the Lower Mainland of BC) in line ETCO2 was used only for the confirmation of tube placement in the intubated patient. Many resourceful practitioners saw the value of this tool and creatively would snip away the in line T piece, inserting the now open hosing into a simple face mask and then having access to microstream™ capnography technology and real time ventilatory telemetry in the conscious patient. Continue reading

Combat Aviation Paradigms for Resuscitationalists

Joe-Novak

From Emcrit.org, Dr Joe Novak’s podcast on Combat Aviation Paradigms for Resuscitationalists.

http://emcrit.org/podcasts/combat-aviation-paradigms/

Whilst Dr Novak’s language focuses on the physician in hospital, the lessons here within can be easily transitioned into the pre hospital environment.

Particularly the concept of Prioritization of Attention and Tasks;

  1. Resuscitate
  2. Differentiate
  3. Coordinate & Communicate

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