hi everyone this is lee here from abc's of anesthesia and right now i'm going to be
demonstrating the front and neck access or surgical airways now this is in the context
of your difficult airway algorithm so for example whatever algorithm you're using
whether it's the difficult airway society or the vortex approach you're going to be
trying all the different methods of supraglottic airway access for example you might be trying to
bag mask and optimize that use an lma or intubate with laryngoscopy and maybe even
try a video learning skill now if all of these things are failing that's when you need to start
preparing for a surgical area and that's what we're going to go through so let's get started
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so this next technique in the algorithm is say you fail the needle crack technique or you've chosen
to surgical technique um andrew heard's algorithm describes the scalpel bougie
technique now i really like this technique just for its simplicity
you essentially just need three pieces of equipment really so that's your scalpel
your bougie and then a size six tube so again with this technique i'm standing on the left side of
the patient because i'm right hand dominant i'm doing that laryngeal handshake finding
out where that cricoid cartilage is and the thyroid prominence and that's your cricothyroid
membrane i'm doing that hold of the larynx larynx with my thumb and forefinger and then
i'm using my scalpel and doing a horizontal incision on the cricothyroid membrane just like so
and now at that point i can point the scalpel down and turn it vertically you can see that there's
a bit of a triangle created and that's where my bougie is going to slide so i then swap my hands
pass the bougie along the surface of the blade and once i'm in the trick here i can
turn it caudal down towards the lungs and push the bougie through now i'm mindful not to push the
breath through too far because i really don't want to cause any trauma down into the into the airway
i remove my scalpel put that safely and usually this is a two-person
technique you know you want to be able to stabilize the bougie
and then also pass a size six tube and at this point i can railroad this tube it down
so that's heading down this is again a variation of the cell digger technique that we'll often use
for line insertions and i give a small rotation and then i really just need to push it down to
the black line just like in a normal intubation that way the cuff is in the trick here i then
take the bougie out once i've taken the bougie out inflate the cuff sometimes you might need
more than five mils just wanna make sure there's no leak there and then connect my ladell bag
and you can see ventilation there of course i can attach my filter and my end tidal oxygen to make
entitled co2 measurement device to make sure that i'm actually in the lungs now once i'm in
the airway with the bougie the technique describes using a wrappyfit connector and this way i can use
this connector insert it onto the end of my bougie and clasp it on with this white locking device
so now that's really firmly fit there this then connects to the one of those 15 22 millimeter
connectors which is the standard type connector and that way i can get some oxygenation in now
while this will give you oxygenation faster using this connector may be a bit slower just because
i can't get the same level of pressure sometimes these wrapy foot connectors have a lure lock which
means like a connector jet ventilation device to get rapid oxygenation sometimes you may not have
a wrappy fit connector in which case you can just use your 14 gauge cannula insert it like
so and then attach your rapid oxygenation device and this may provide some level of oxygenation
through a jet ventilation device even though i didn't have the proper wrappy fit connector
which would sit there now even though this is the technique that's taught by the android algorithm
i know that in some situations we might not have a rapidfit device and i might not have
all my equipment ready for rapid oxygenation once i've got the bougie in and maybe my bougie doesn't
have a hole not they're not always going to be this way therefore i may just want to railroad
that size 6 tube as quickly as possible to get my patients safe with a definitive airway i'm
now going to show this in one smooth sequence so laryngeal handshake making a vertical incision
opening up that triangle swapping hands loading the bougie along the blade towards the airway
i can either confirm with the wrapping i can use the rapid connector or
just connect my tube straight off
and then railroad my tube take my boujee out inflate the cuff and then put that on
so thanks so much for watching this series of videos i hope they were really useful to you
please share with anyone who might be interested and i'll see you next time for the next video
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