Vomitology!
A static or dynamic soiled airway can be extremely challenging during airway management. A clinician must always assume that any patient has the potential to vomit.The NAP4 study showed through a prospective observational study, that even seasoned anesthetist could not always predict which patients were at risk for aspiration during airway management. The risk factors for vomiting and aspiration in theatre describe our everyday patients in EMS. (1)
"They took an oral airway like a champ.. no need to paralyze!"
It is beneficial to understand that paralytics purpose is not only to facilitate intubation, but also to protect against vomiting & aspiration. The reason this is mentioned is because some providers will feel “if the patient accepts an oral airway, they will accept an ETT without difficulty". This thinking is flawed and dangerous. In the emergent setting, paralytics are recommended to facilitate intubation. Sedation alone will reduce upper and lower esophageal sphincter (LES) tone. Paralytics can attenuate this change in LES barrier pressure. However, paralytics will also reduce the risk of aspiration.
I see many services who do not have their medical controls permission to paralyze their patient prior to intubation. This conversation ends with them telling me they can do a "medication assisted" intubation. This is essentially the art of snowing someone deep enough that they don't mind you intubating them. This technique does not yield high success rates in the literature and is associated with a faster desaturation rate. (3)
The rigid suction catheter can be used to evacuate the emesis, depress the tongue, or channel your gastric tube into the stomach. The ideal suction catheter should have a big enough aperture to suction viscous contaminate without clogging. For this reason, we do not recommend utilizing the Yankauer catheter in acute airway management. Here are a few examples of EMS providers who were asked to perform airway decontamination with the Yankauer.
Suction Assisted Laryngeal Airway De-contamination (S.A.L.A.D)
Dr. James DuCanto set on a quest to provide clinicians with the confidence and strategy to quickly recognize, react, and manage a soiled airway through simulation.This technique is called SALAD and has spread throughout the world. The steps for this procedure are listed below. 1. With the suction catheter in the right hand the “dagger” position, suction the immediately visible contaminate from the hypo-pharynx.
2. Use the suction to displace the tongue and jaw anterior while slowly advancing your video or direct laryngoscope (video is preferred). The suction should lead the way to prevent the camera from getting soiled.
3. Once you can view the vocal cords, remove the suction catheter from the right side of the patients mouth and enter it on the left side. The suction will then be strategically placed into the esophagus with continuous suction.
4. Now that any acute emesis will be immediately evacuated, secure your ETT. It is recommended that you use a soft suction catheter through the ETT if contaminate is noted.
5. If suction catheter has a large enough internal diameter, a OG/NG tube can be sized and placed down the catheter and into the esophagus. This suction catheter can then be removed utilizing a push pull method so as not to displace the gastric tube. The catheter will remain at the proximal end of the gastric tube for the remainder of transport.
Now watch my friend Dr. Jason Bowman from EMSPOCUS demonstrate superb "Vomitology" using the DuCanto catheter during a dynamic barfing patient scenario.
Large Food Particles
If the airway contaminate contains food particles which appear too large for the internal diameter of your suction catheter, a large endotracheal tube in conjunction with a meconium aspirator may be useful. This technique has no supported evidence other than collective anecdotal and practical experience. Here is a video of this being performed by Sam Ireland.
**Conflicts of Interest**
We must disclose that FOAMfrat is occasionally contracted with SSCOR to demonstrate the use of the DuCanto catheter. However, we honestly believe this is the most elite suction catheter on the market for emergency airway management. If you are interested in obtaining a free sample click on the link below.
References
1.NAP4 https://www.rcoa.ac.uk/node/4211
2.https://www.openanesthesia.org/esoph_sphincter_tone_anes_drugs/
3.62 Wang H.E., O’Connor R.E., Megargel R.E., et al: The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 4. 14-18.2000; Abstract