This post contains some truly awesome educational resources. Make sure you can use simple airway adjuncts, including the oropharyngeal and nasopharyngeal airways. Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement. Optimise the position of the patient before you start — this step is often overlooked in the emergency setting. Steps of laryngoscopy Remember to use bimanual laryngoscopy. Make sure you can tell the difference between the larynx and the esophagus!
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We are serious about airway education. Richard Levitan Dr. Levitan was in the first class of Emergency Medicine residents at Bellevue Hospital , and subsequently worked in academic, high-volume, inner-city trauma hospitals in NYC and Philadelphia for 25 years Bellevue, Lincoln, Penn, Einstein, Jefferson.
Starting in he began working in rural, critical care access hospitals. He now balances this clinical activity with teaching courses, speaking engagements, and device development. He has been involved in numerous device development projects with various manufacturers. He did early design testing and wrote the first published paper on the I-gel supraglottic airway.
Levitan has designed and built his own unique intubation manikins with anatomic variation for teaching laryngoscopy the Airway Training Series , as well as a unique anatomically correct surgical model The Airway Cam Surgical Trainer , which uses an inexpensive three-layer skin analogue. He has published extensively on laryngoscopy and airway management, and holds an Adjunct Professor appointment at Dartmouth Geisel School of Medicine, as well as a Visiting Professor appointment at the University of Maryland School of Medicine.
Recognizing the challenges of skill acquisition and the lack of imaging, he developed a means of displaying direct laryngoscopy as seen by the operator.
The Airway Cam is a head mounted video camera, optically aligned with the dominant pupil, that is able to image direct laryngoscopy from start to finish; it was patented in He invented a grading system for laryngeal exposure with imaging called the Percentage of Glottic Opening Score POGO score , which has been used my researchers worldwide.
Levitan in numerous research papers on laryngoscopy, including head-elevated laryngoscopy positioning HELP , bimanual laryngoscopy, and comparisons of cricoid pressure, BURP, and bimanual laryngoscopy.
Cadaveric Research and Training. Levitan has been involved with airway education and research since , using the Airway Cam to record procedures in live patients and cadavers. He started cadaver-based airway management courses beginning in with Dr.
William J. Now run with Dr. Jorge Cabrera Jackson Memorial Hospital , these on-going cadaver courses are offered monthly in Baltimore. The success of the Baltimore course has led to Dr. Research we have conducted in cadavers has defined a best practice approach to laryngoscopy now widely adopted that we created and promoted including: ear-to-sternal notch positioning, bimanual laryngoscopy, and straight-to-cuff stylet shaping.
Airway Cam educational materials—videos, book, and pocket guides—have been critically acclaimed by leading medical journals around the world.
Teaching this procedure has always been a part of the Baltimore course. Through thousands of participants and decades of cadaveric courses, Dr. It is particularly difficult in obesity, and much less evident in woman than in men.
Realizing that the first skin incision should be a vertical incision allowing wound exploration and verification of the cricotyhroid membrane , Dr. The hyoid, thryoid and cricoid cartilages make up a rhomboid that can easily moved from side to side. The most reliable landmark in the surgical airway is the broad lamina of the thyroid cartilage and this is reliably palpable, even in women.
The cadaver lab permitted intensive investigation into the optical and mechanical challenges of inserting tracheal tubes into the trachea with a variety of devices. Tracheal tubes interact with the corrugation of the rings and the inclination of the trachea as it descends into the thorax. Tubes can block the line of sight to the target with both direct and video laryngoscopes , and though video devices often make exposure much easier, they frequently make tube delivery more difficult.
Levitan and soon to be commercially available. One device for all intubations, direct laryngoscopy and video laryngoscopy. A better bougie than a standard bougie, a better stylet than a standard stylet. Can be used a bougie in standard fashion, or with a hyperangulated shape for hyperangulated video laryngoscopy. Can also be used as a stylet in either standard straight-to-cuff shape, or as a hyperangulated stylet. Unique hexagonal cross-sectional shape, unique pre-molded overall size overall package dimension is the same as a tracheal tube.
Watch for more information on availability from Intersurgical, Ltd. Intubation, especially using RSI medications, was frequently complicated by peri-procedural desaturation. Apart from pre-oxygenation, there were no techniques employed to prevent destauration during laryngoscopy and intubation. Upon hearing of low flow oxygen to extend safe apnea in the morbidly obese in elective anesthesia , Dr. Levitan started experimenting with higher flows albeit through standard nasal cannulas in emergency RSI situations.
Levitan collaborated with Dr. Scott Weingart. Disseminated through FOAM ED emcrit and other podcasts , and a seminal paper in Annals of Emergency Medicine , this technique has gained worldwide acceptance in emergency medicine, critical care, and anesthesia. OOPS—Oxygen On Pull the mandible forward, Sit the patient up—using standard nasal cannulas at high flows to rapidly reverse desaturation in procedural sedation—has been promoted by Dr. Levitan as a better initial response to hypoxia than bag mask ventilation.
Setting the standard for positioning: The Ear-to-sternal notch line Positioning is critical for for both the mechanics of laryngoscopy and also the physiology of oxygenation. With the goal of defining the ideal position for intubation and airway management, Dr. Levitan created an objectively defined end point—-the ear-to-sternal notch line. Ear-to-sternal notch line is a horizontal line from the external auditory meatus to the sternal notch. This raises the head relative to the chest; the face place should be horizontal to the ceiling.
This ideal positioning applies to both adults and children.
Practical Emergency Airway Management
Introduction 0 Last week I attended Dr. It was a teriffic course, which I would recommend to anyone looking to improve their airway management skills. For those of you unable to attend the course, here are some points which were particularly interesting to me. Respect the vomit 0 Vomit can convert an easy airway into a very challenging airway by impairing just about any method of intubation. Care should be taken to avoid this. If the patient is at high risk for emesis i.
Isaak Iljitsch Lewitan
Rich knows this better than anyone, having examined 20 cadaveric airways per month for the past 16 years in addition to clinical research. Cannot Oxygenate Face Flat in Neutral position. There are a few reasons this is true and it is important to understand them. Not only will it help improve patient outcomes but it will make you better at managing airways.
There is a unique focus on airway anatomy and imaging combined with one-of-a-kind opportunity to practice the techniques on a large variety of non-embalmed, specially prepared cadavers. This is the only cadaver airway course available. This course teaches practical, effective skills and strategies for adult and pediatric intubation that promote patient safety and increase provider confidence. Topics covered include orotracheal intubation, laryngoscopy, surgical airways cricothyrotomy, tracheotomy , video laryngoscopy, fiberoptic intubation, nasotracheal intubation, pediatric intubation, and rescue ventilation devices such as the laryngeal mask airway.
Own the Airway!