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Everything you need to know about the new glidescope:

Tips on using the Glidescope

1. Looking at the mouth, first insert the Glidescope into the midline of the oral cavity, then look at the monitor and advance the Glidescope to view and then elevate the epiglottis, exposing the glottis.

2. Less force is required to expose the glottis using a Glidescope than with conventional laryngoscopy because of its steep angle. The Glidescope can be used to elevate the epiglottis indirectly by placing the tip of the handle into the vallecula (Macintosh technique), or by using the handle tip to directly lift the epiglottis (Miller technique).

3. Once optimal glottic view is obtained on the monitor, look back at the mouth to insert the ETT immediately adjacent to the handle, then, as the tip of the ETT approaches the tip of the Glidescope, look back at the monitor to guide the ETT through the vocal cords.
4. If the ETT does not easily pass into the glottis, use your thumb to push the stylet out of the ETT 2 inches as you advance the ETT through the vocal cords.

5. It may be easier to advance the ETT if the view of the glottis is relaxed, so that you see less of the cords. If using a conventional malleable stylet rather than the Glidescope stylet, bend the stylet to 50-60 degrees at the cuff to match the Glidescope handle.

For more insight on using how using a glidescope requires a different technique compared to direct laryngoscopy, have a read of Levitan’s paper on the subject.

Contact phillip.andrus@mssm.edu with any problems regarding the Glidescope.

Dear Doctors and PAs,

We now have an easy, 7 minute process for high level disinfection of our vaginal probe for the ultrasound machine! Because the disinfection needs to be logged by a credentialed person, the techs will be in charge of this process.

We are also going to be taking our Glidescope blades to the sterile processing department (SPD) for sterilization until further notice.

I am forwarding Dwayne’s email below so you can see the workflow message that has been sent to the techs and nurses.
________________________________
From: Raymond, Dwayne
Sent: Friday, April 13, 2012 5:39 PM
To: Gardner, Keri; Baumlin, Kevin; Vella, Adam (MSSM); Fakih, Francine
Subject: High Level Disinfection Processes

There will be no change in practice until Monday (4/16) with another notice.

Process change #1, pending a few things on Monday:

After use of the Sonosite probe for vaginal exam, the Charge Nurse must be notified, by the examiner, to facilitate disinfection of the probe prior to next exam.

Thereafter, the Charge Nurse will select an ED Technician (trained in the new process) that will remove the probe and cable from the machine for transport to the East Dirty Utility Room. There a Trophon Machine that uses heated vapor and a concentrate of H2O2 will be used for disinfecting process.

Only those who have completed a criterion checklist and competency under the supervision of persons designated can use the machine.The process takes about 7 minutes.

Process change #2, pending a few things on Monday:

The Glidescope blade and stylet used in the AED will be sent to Sterile Processing Distribution for disinfection. We will be given another set in exchange. Note, the TAT for disinfection is 1 1/2 hours.

We will need to look into the use of disposable blades for the pediatric ED in particular. There isn’t presently a exchange set for pediatrics.

Thank you/Dwayne

The Glidescope blade and stylet used in the AED will be sent to Sterile Processing Distribution for disinfection. We will be given another set in exchange. Note, the TAT for disinfection is 1 1/2 hours.

March 13, 2012

Nursing Practice
Alert

Storage of Laryngoscope Blades

? New Joint Commission Requirement: After sterilization, the laryngoscope blades must be placed in a sterile dated labeled package and maintained in that package until use.

? Laryngoscope blades: cannot be stored outside of sterile packaging (e.g., peel wrap). Examples of incorrect storage include unwrapped blades on top of a code cart or unwrapped blades in an intubation cart/box/drawer.

? All laryngoscope blades must be processed in the Sterile Processing Department.

? Laryngoscope handles: considered contaminated after use and must be wiped down with hospital approved disinfectant.

EM Clinicians:

There is a manufacturer-side succinylcholine shortage and, for the indefinite future, when you call for succinylcholine, it may not be there.

The alternative agent for paralysis in RSI is rocuronium, which is dosed at 1.2 mg/kg. The onset is 45-60 seconds, and the duration is much longer than succinylcholine; at this dose generally 45-75 minutes. There are no contraindications (other than the contraindications to RSI itself). At Sinai, rocuronium is kept in the med room refrigerator in both the adult and pediatric zones.

Let me know if you have any questions.

reuben

Cheat Sheet

EMFaculty, EMResidents:

Hi all,
Recently, there was a case where an ILA was used as a rescue device, but nobody, including anesthesia, was familiar with how to transition this device to an endotracheal tube .

Joe and I discussed this in May 2007 when we first bought these devices.

Here is a review:

The ILA  is a device specifically designed for ease of ET tube placement.

After the ILA is placed and the pt is reoxygenated, ET tube placement can be accomplished by either:

Placement of the bougie (I prefer using the straight end), and then placement of the tube over the bougie with the ILA still in place.

or

Placement of the intubating stylet with an ET tube over it through the ILA, which allows direct visualization of the cords through the ILA.

In both cases you need to remove but not lose the 22 mm adapter from the top of the ILA

please watch these two videos:

the videos also show how to remove the ILA after ET tube is placed and confirmed.

One key move that Rikki and I learned was to make sure the patient is paralyzed during these maneuvers or you might wind up with a face full of GI bleed blood, ummmmm GI bleed blood.

ask Joe or I if you have any questions

Scott Weingart, MD FACEP
Division of Emergency Critical Care
Department of Emergency Medicine
Mount Sinai School of Medicine

[Update 8/19/09]

EMFaculty, EMResidents:

You complained, and then you complained some more. Now we have a new and improved Glidescope tethering system, see photo.

We have installed two very sophisticated devices that attach the blade and the stylet to the base on retractable strings. To use, TURN THE KNOB to loosen, then, once you’ve gotten the string out to length, turn it the other way to tighten. No more dangling phone cords.

Remember, to clean: move the entire unit into the dirty utility, unplug the video cable and cap the digital port on the blade, wash off in water, dip blade and stylet into sterilizing solution for one minute, wash off again in water, dry with paper towel, re-attach the video cable to the digital port, and put the unit back opposite the resus computers.

Let me know if you have any questions and keep those complaints coming.

Thanks to Nicos, Scot, Phil, Micah, and Vaishali.

reuben

Overview

Glidescope is stored with ultrasound machines between north computers.
Cleaning Solution is in the North Zone dirty utility room.
Glidescope should be brought to bedside for all intubations, at the discretion of the treating team.
Can be used as the primary airway device, or as a rescue device after unsuccessful conventional laryngoscopy.
Can be used with RSI technique or awake technique.

For educational purposes, PGY I and II residents should generally use conventional laryngoscopy; PGY III and IV residents have the option to use the Glidescope. However, provider roles are always at the discretion of the treating team.

Post-Intubation care of Glidescope

Intubating resident is responsible for cleaning and replacement.
Bring glidescope to North Zone dirty utility.
Disconnect data cable and place waterproof cap over data plug.
Clean handle and stylet using running water.
Sterilize handle and stylet by dipping both into sterilizing solution for 1 minute.
Dry off handle and stylet.
Return Glidescope to its special place.

Tips on using the Glidescope

Looking at the mouth, first insert the Glidescope into the midline of the oral cavity, then look at the monitor and advance the Glidescope to view and then elevate the epiglottis, exposing the glottis.
Less force is required to expose the glottis using a Glidescope than with conventional laryngoscopy because of its steep angle. The Glidescope can be used to elevate the epiglottis indirectly by placing the tip of the handle into the vallecula (Macintosh technique), or by using the handle tip to directly lift the epiglottis (Miller technique).
Once optimal glottic view is obtained on the monitor, look back at the mouth to insert the ETT immediately adjacent to the handle, then, as the tip of the ETT approaches the tip of the Glidescope, look back at the monitor to guide the ETT through the vocal cords.
If the ETT does not easily pass into the glottis, use your thumb to push the stylet out of the ETT 2 inches as you advance the ETT through the vocal cords.
It may be easier to advance the ETT if the view of the glottis is relaxed, so that you see less of the cords.
If using a conventional malleable stylet rather than the Glidescope stylet, bend the stylet to 50-60 degrees at the cuff to match the Glidescope handle.

Contact reuben.strayer@mssm.edu with any problems regarding the Glidescope.

pdf version available here.

Teaching points summary:

* Testing the gag reflex is no longer thought to be an appropriate maneuver for assessing airway reflexes as it is neither sensitive nor specific and can provoke vomiting.

* Patients likely to desaturate quickly after pre-oxygenation include the obese, kids, pregnant women, and any patient with an oxygenation insult (pneumonia, pulmonary edema, asthma/COPD, pneumo/hemothorax, pulmonary contusion, etc).

* Although RSI with conventional laryngoscopy is safe and effective for most intubations, its appropriateness must be explicitly considered in every case. The less urgent the intervention, and the more difficult airway features present (difficult laryngoscopy, difficult bag-valve-mask, difficult cricothyrotomy) the more suitable is an awake technique.

* When in the midst of an intubation, the response to hypoxia is ventilation, not repeat laryngoscopy.

* Bag-valve-mask ventilation should routinely be performed with nasal and oral airways in situ as well as a two hands-down technique.

* If BVM ventilation is ineffective, the response should not be repeat laryngoscopy but rather the optimization of BVM ventilation. The most important interventions to perform are to re-position the patient, insert two nasal airways and an oral airway if not already placed, replace dentures if out, use a larger mask size, and change to a more experienced BVM operator. The use of airway adjuncts that may be blindly and quickly inserted, such as an LMA or combitube, is also appropriate to effect ventilation in an otherwise difficult to bag patient.

* Continuous capnography should be used as a tube confirmation technique when possible. If colorimetric capnography is used, a bright yellow response should be sought after six breaths.

* Have a low threshold to use the gum elastic bougie.

* Think of laryngoscopy as epiglottoscopy, as the purpose is to first control the tongue and then to find and control the epiglottis. Perform bimanual laryngoscopy by using your right hand to manipulate the thyroid cartilage to optimize glottic view.

* Patients being bagged with high FiO2 require surprisingly little ventilation to fully oxygenate. Bag slowly and gently to minimize gastric insufflation.

* For all intubations, consider using the intubation checklist, overflowing with handy reminders and pearls. Use the Sinai EM Updates page and click on “airway.” http://mssmem.com.

Process Results:

* The glidescope handle, previously behind a key, is now in an easily-opened drawer and should be immediately available when needed.

* Airway equipment, including difficult airway adjuncts and implements for performing awake intubation, will soon be organized on a cart so as to provide immediate and reliable access.

* Airway management strategies were reviewed this morning and residents were trained in the two-hands down method of bag-valve-mask ventilation.

This document provides a checklist for performing intubation in the ED.

This document outlines the use of capnometry in the MSSM ED.

Propofol has been approved for use in the ED for post-intubation sedation and may be ordered in IBEX by all attendings.

It should not be used as a continuous infusion for patients under age 18.

The starting dose is 5 mcg/kg/min, titrated upwards by 5 mcg/kg/min every 10 minutes until desired sedation level is reached.

An infusion chart is available on the EHCED site:

http://www.ehced.org/Drips/propofol.pdf

I spoke with Robert Asselta today and he reported that all nurses should be able to hang and deliver propofol as a standard infusion, effective immediately.

For now, only use Propofol on intubated patients being monitored with continuous ETCO2 and automated, repeating blood pressure checks. Although propofol offers minimal if any benefit in most intubated patients when compared to midazolam, we must demonstrate a safe record of use before we petition the P&T committee to allow us to use it for RSI and procedural sedation, where it does offer significant advantages in certain situations. Propofol’s rapid offset of action does have particular utility in the patient intubated for CNS lesions, as the patient’s neurological status can be quickly re-evaluated after discontinuing the infusion.

Propofol causes respiratory depression, which is not an issue in an intubated patient, and hypotension, which can be. Be mindful of hypotension in susceptible patients.

I have pasted the summary I sent out months ago below for further information.

Thanks to all the MSSM attendings for suffering through the preliminary steps, thanks to Haru and Ruben for their efforts. Looking forward to seeing the milk-colored infusions.

reuben

* Propofol is a potent sedative-hypnotic that is structurally
different than but behaves similarly to the barbiturate class. It
produces dose-related sedation and amnesia, up to and including deep
sedation, in which case patients are unresponsive to painful stimuli
and may be apneic.

* Propofol has become popular for use in emergency medicine because
of its unique pharmacokinetics. When given as a bolus, onset of
action is generally within 1 minute, and duration of action is
generally not longer than several minutes. Patients are generally
completely alert within 15 minutes.

* Propofol may be used as an infusion to maintain sedation in
intubated patients. The recommended starting dose is 5 micrograms /
kg / minute, to be titrated to effect every 10 minutes. Note that 5
mcg/kg/min is a very small dose. Propofol is particularly well-suited
for this purpose if following the patient’s neurological exam is
important, as the effect wears off completely within 15 minutes of
holding the infusion.

* Propofol may be used to facilitate painful procedures. The
recommended dose is 1 mg/kg bolus, but experienced providers use
anywhere from .5 to 1.5 mg/kg as their starting doses. Repeat dosing,
usually at .5 mg/kg, must be provided quickly if needed, every 3
minutes at the longest, as the effect is so short-lived.

* Propofol is the most popular agent among anesthesiologists for RSI,
and may also be used to treat refractory delerium tremens and status
epilepticus. We can discuss these indications later as need and
interest warrant.

* Propofol is contraindicated in patients with egg or soy allergy, as
both of these ingredients are in the vehicle.

* Propofol causes pain at the injection site. This pain can be
reduced by adding lidocaine, .5 mg/kg, to the syringe. This is
routinely done in the OR and rarely done in the ED.

** Propofol routinely, reliably produces respiratory depression,
including apnea, as well hypotension. However, the clinical relevance
of these effects is greatly reduced by propofol’s ultrashort duration
of action.

-When end-tidal capnography is utilized (and it should be, if
available), there is no benefit to withholding supplemental oxygen.
In a healthy adult, adequate preoxygenation allows for periods of
apnea much greater than is routinely encountered with bolus propofol,
without desaturation. My experience is that the bolus is delivered,
the patient becomes unconscious, stops breathing, and starts
breathing within about a minute, without the saturation moving from
100%.

- Hypotension is to some degree prevented by pretreatment with
fluids; in any case the drop in blood pressure is brief and rarely of
clinical significance. In patients where hypotension is a particular
concern, it can be abolished with phenylephrine 100 microgram boluses.

** Though propofol has been demonstrated to be safer than
alternatives many of us are more comfortable with ( e.g. fentanyl /
midazolam), those who use it must anticipate its side effects and be
prepared to support blood pressure and ventilation as needed.

Tips on Advancing the Endotracheal Tube

New GlideScope® users often achieve an excellent view with the
GlideScope® but may experience some difficulty advancing the
endotracheal tube. This may be caused by two factors:

The first factor is excessive lifting or pushing of the glottis by
the GlideScope® blade. Maximum laryngeal exposure may not
facilitate intubation; reducing the elevation applied to the laryngoscope
may make inserting the endotracheal tube easier.

The second factor is the angulation of the tip of the endotracheal
tube. A GlideScope® Rigid Stylet (PN 0800-0309) that is
designed to match the angulation of the GlideScope® blade is
now available. The GlideRite® (PN 0830-0075) endotracheal
tube soft tip technology may make passage of the endotracheal
tube easier and less traumatic. Please contact a Verathon Medical
™ representative for more information.

If using a malleable stylet, we recommend bending the tip of the
stylet to at least 50–60° to match the angle of the GlideScope®
blade. An angle that is larger than 60° may make it difficult for
some users to advance the endotracheal tube.

Other methods of configuring the stylet have been developed by
GlideScope® users worldwide and have proven to be effective.
For more information on alternative methods of stylet configuration,
please contact your Verathon Medical™ representative.

GlideScope® Video Laryngoscope

Stylet

GlideRite™ Endotracheal Tube

Bend the proximal tip of the stylet.

If using a malleable stylet, the proximal tip of the stylet may be
bent backwards to permit one hand operation of the endotracheal
tube. The GlideScope® Rigid Stylet is already designed to
be used in this manner, as shown in the illustration below.

Introducing the endotracheal tube.

The endotracheal tube should be introduced behind or immediately
adjacent to the GlideScope® blade. The proximal end of
the endotracheal tube should be carefully introduced between
the vocal folds. The operator should take care not to damage the
cuff, teeth or oropharynx during insertion.

Withdraw the stylet 5 cm (2″).

Using the right hand, advance the endotracheal tube while simultaneously
withdrawing the stylet with the thumb. The stylet
should be withdrawn approximately 5 cm (2″). This straightens
the tip of the endotracheal tube and permits it to enter the larynx
while the stylet continues to provide rigidity to the body of the
endotracheal tube.