Be proactive with an alternative airway box
When faced with managing a difficult airway, the pressure of time is coupled with the pressure of assembling supplies that may be rarely used. Some EDs have constructed their own alternative airway kits in preparation for this scenario. In most cases, bright red fishing-tackle boxes or toolboxes are used to store these supplies.
Valuable minutes can be saved by avoiding rummaging through drawers for airway supplies. "Another major benefit is the additional comfort you feel, knowing that if plans A and B don’t work, you have plans C, D, E, and F in a box ready to go," says Hartmut Gross, MD, FACEP, assistant professor of emergency medicine at Medical College of Georgia in Augusta.
Store supplies in one location
Problems can arise when all necessary supplies aren’t stored in a single location. "When you are faced with an airway problem, you don’t have much more than five or ten minutes to correct the situation," says Alejandro Mondolfi, MD, a fellow in pediatric emergency medicine department at Boston Children’s Hospital. "That’s why you need preassembled equipment. That way, everybody knows where it is and can have it accessible in a brief period of time."
The ED stores its airway supplies in a big red toolbox marked with a sign reading, "Difficult Airway Box," located right at the head of the bed in the trauma room. "That way it’s no more than two feet from where the airway is going to be," notes Mondolfi. A list is kept inside the box, so whenever an item is used, it can be replaced immediately. The kit contains:
• preassembled jet ventilation setups;
• angiocaths for needle cricothyrotomy (18G, 16G, 14G);
• Seldinger-type cricothyrotomy kit (scalpels, skin retractors, curved kellys, small-cuffed ETT);
• laryngeal mask airways (LMAs) — size 1 and 2, will work for patients up to 20 kg;
• tape, benzoin, lubricant, 20 cc syringes;
• taped to the inside of the box are the ASA "difficult airway" algorithm and the LMA size guidelines.
Restocking is important. "We keep a tearaway lock on the airway box, so when the nurses do routine checks they replace anything that’s missing," says Alfred D. Sacchetti, MD, FACEP, research director of the emergency department at Our Lady Of Lourdes Medical Center in Camden, NJ. "If supplies are scattered around the ED, nobody knows that we used the last number 7 ET tube last week, and nobody thought to replace it."
A disposable LMA for pediatric and adult patients also is included in the airway kit at Our Lady of Lourdes’ ED. "They’re an ideal fallback for the difficult airway and really make a difference in a lot of patients," says Sacchetti. "They’re now coming out with cheaper disposable LMAs, which would make them universally available. In the past, they had to be reused, and they were about $200 apiece, which was prohibitive for a lot of EDs."
Disposable laryngoscope blades also are kept in the ED’s airway box. "They’re now pretty much equivalent to the traditional metal blades, and you can put two or three disposable blades in there and don’t have to worry that when you use one it has to go down to the OR to be cleaned and replaced," says Sacchetti. "In the past, if you had a couple of intubations in one day, your equipment may wind up being cleaned, and you wouldn’t have immediate access to it." Another advantage to disposable blades is their cost. "Since they’re inexpensive, they can be kept in more than one place."
Having an airway box in place can be reassuring, especially since the scenario isn’t a common occurrence in many EDs. "The situation doesn’t come up very often, and you don’t want to be saying, Where did we put that thing last year?’ when it does," says Gross.
The process of creating the kit lent itself to some education efforts. "The first thing we did was explain to staff why it was important and coordinated staff to assemble the kit," says Mondolfi. "We also did inservice on advanced airway management techniques."
Creating a storage box for these supplies is an excellent opportunity to expand staff understanding of advanced airway procedures and equipment. "When you prepare a kit, you kind of standardize things, so it’s a way of teaching nurses, respiratory technicians, and physicians about the equipment and how to use it," says Harley Eisman, MD, a pediatric emergency medicine fellow at the Montreal Children’s Hospital. "Like any ED, we have staff with different levels of training, so like with any other new product introduced, we’ll have to explain to them how the equipment is used."
The hospital held a three-hour workshop that demonstrated airway techniques with mannequins to familiarize faculty and residents with airway equipment and refresh them on techniques. "Since you don’t typically see this in the ED, it may be your only chance to get hands-on experience, and it’s not the same reading it out of a book," Gross explains.
Ongoing training is essential when new pieces of equipment are added to the airway box. "We inserviced everybody when we introduced laryngal mask airways, noninvasive pressure support ventilators, newer paralytics," says Sacchetti. "Most of physicians are up to speed, but want to bring nurses up to that same level."
The following supplies are kept in the alternative airway box at Medical College of Georgia’s ED:
• Cook retrograde intubation set—trach light with wands;
• needle cricothyrotomy kit;
• Melker cricothyrotomy kit;
• jet insufflator.
For some EDs, a single airway box is insufficient. "We have a separate pediatric crash cart with all the airway equipment and a separate airway box for adult intubations," Sacchetti explains. "The advantage to that is, occasionally there will be codes called in radiology or ambulatory surgery units which are on the same floor as the ED, so we can just grab that box and go."
The ED also has added a second airway box, with one stored beside the resuscitation bed and the other kept at the foot of the bed. "At some point, we may simply combine them into a bigger box," says Sacchetti. "By the time you added all your ET tubes, laryngoscope blades, handles, LMAs, it started to get stuffed, so we overflowed into another box."
Although many EDs find airway boxes work well, other methods may be equally convenient. "It’s not so much having an airway box specifically — It can be an airway drawer, crash cart, or shelf, and you should pick what works for you," says Sacchetti. "The big advantage of a portable box is you can grab it and run. You could also have a skeleton box with one of each ET tube, laryngoscope blade instead of three or four of everything."
Even for EDs that frequently do airway management benefit from a singular storage location. "We do about some type of advanced airway management about 100 times a year, so for us, having the airway box is a matter of having things organized, and we’re more comfortable knowing where the equipment will be when you need it," says Sacchetti.
A major benefit is having several options on hand for alternative airway management. "Having your equipment organized makes sense," says Sacchetti. "When someone needs an airway managed is not the time you want to be running around looking for bits of equipment."
[Editor’s note: Items from the Medical College of Georgia’s alternative airway kit can be ordered by calling Anesthesia Associates at (619) 744-6561 or Mercury Medical at (800) 237-6418.]