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Clinical Summary

Hematemesis (see Video 22.6), emesis (see Videos 22.7 and 22.8), and oropharyngeal bleeding (see Videos 22.9 and 22.10) during intubation increase the probability of aspiration and its complications. Having a strategy for active vomiting and bleeding during intubations is prudent to prevent or lessen the volume of aspirated vomitus.

Vedio Graphic Jump Location
Video 22-06: Difficulty Passing Tube and Stylet
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Vedio Graphic Jump Location
Video 22-07: Excessive Airway Soilage
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Vedio Graphic Jump Location
Video 22-08: Tube Bevel Hung Up on Large Posterior Cartilages
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Video 22-09: Suctioning Excessive Bleeding
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Video 22-10: Huge Posterior Cartilages
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Possible Strategies

  1. Place the patient in reverse Trendelenburg position to use gravity to prevent further vomiting (see Fig. 22.34).

  2. Perform deliberate esophageal intubation to direct emesis away from the oral cavity (see Fig. 22.35).

  3. Use a large-bore DuCanto suction catheter rather than a Yankauer (see Fig. 22.36).

  4. Use the suction-assisted laryngoscopy and airway decontamination (SALAD) technique.

    1. Lead with suction during laryngoscopy (see Fig. 22.37).

    2. Decontaminate the oropharynx (see Fig. 22.38).

    3. Follow the suction with direct laryngoscopy or video laryngoscopy (see Fig. 22.39).

    4. Visualize the epiglottis and vallecula (see Fig. 22.40).

    5. Decontaminate the larynx.

    6. If repeated soilage, place the suction catheter to the left of the laryngoscope for continuous decontamination during tube passage (see Fig. 22.41).

    7. Place ETT and remove stylet.

    8. Suction the ETT (see Fig. 22.42).

    9. Begin ventilation.

FIGURE 22.34

Reverse Trendelenburg. Continued soilage may benefit from this feet-down position. It may improve the ear-to-sternal notch positioning also. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.35

Deliberate Esophageal Intubation. This strategy is used with continuous soilage of the oropharynx. Soilage is directed away from the working space. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.36

DuCanto and Yankauer Suction Catheters. The DuCanto catheter offers a 6.6-mm internal diameter (ID) at the tip compared to the 3-mm ID tip of the Yankauer. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.37

Lead with Suction. Real or simulated airway soilage should prompt the laryngoscopist to lead with suction. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.38

Decontaminate the Oropharynx. Do this prior to entering the oral cavity with a video laryngoscope. (Photo contributor: Lawrence B. Stack, MD.)

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