A Whole New World


    A Whole New World

    We all love FOAM, and we all love airway. Today’s pearl will introduce you to a corner of FOAM you may not have come across, as well as a corner of airway management you might not know about.

    I’m a big fan of Jed Wolpaw’s Anesthesia and Critical Care Reviews and Commentary podcast. Many of the episodes overlap with emergency medicine topics, and it’s a great source of pearls from another perspective. One of these pearls is the paraglossal approach to intubation using direct laryngoscopy with a straight blade.

    While many of us are most comfortable reaching for a curved Macintosh blade, or a hyperangulated VL blade of some sort, our airway boxes stock Miller 2s and 3s at both sites. While anecdotally, most of us don’t use a straight blade routinely, I think we are all familiar with their use. If not, get back to the books, and then hit the ORs for some practice.

    But did you know there’s a whole other way of using these things? Behold, the paraglossal approach:

    Typically, the straight blade uses a midline approach to visualize and then directly lift the epiglottis. In the video above Dr. Levitan (also of FOAM fame) demonstrates the alternative paraglossal approach. The basic steps are:

    • With straight blade, enter the mouth as far to the patient’s right as you can
    • Keep advancing, hugging the right side of the mouth
    • You will eventually just….see cords

    In the first clip above you’ll see Dr. Levitan briefly gets a view before having to do some epiglottis manipulation, but in the second, the epiglottis is totally bypassed. Dr Wolpaw goes in to more detail about this technique in this episode of his podcast.

    I am definitely not advocating that you go out at try this on your next sick ED intubation. But on your next trip through the operating room, consider giving a shot. I’ve talked to several anesthesiology attendings about this technique, and each one I’ve spoken to has at least one war story that comes to mind where this was the thing that saved their bacon on hairy airway. It’s one more tool to put in your armamentarium.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Quadriceps tendon rupture. Xray or not?

      The quadriceps tendon attaches the quadriceps muscle to the patella. Tears most often occur just above the insertion on the patella. They more commonly occur in men (8:1 ratio) and patients report hearing a poppingRead more

    • Mandible Fracture? That’s what a tongue depressor is for…

      So you’re working a Saturday overnight B side shift at Elmhurst. Its 3am and you have a patient in the hallway who looks questionably intoxicated and has been assaulted. Grossly he has no facial orRead more

    • Put down that FOBT

      “The HgB has dropped, have you checked a guaic?” How many times have you checked a FOBT in your workup for anemia? Let’s take a look at what FOBT is supposed to be used for. FOBTRead more

    • A ‘normal’ chest Xray

      What do you see when you take a look at this Chest radiograph? It isn’t immediately noticeable (and was read as normal), and is a good reminder of why you should always check your ownRead more

    • Overshot that INR

      There have been a few cases of supra-therapeutic INR in the Sinai ED recently, and at the request of one of our superstar interns, below you will find a brief set of recommendations regarding SupratherapeuticRead more

    • Ketamine PSA with Desaturation

      During a busy day in the ED, it becomes apparent that the pulling and yanking on your patient’s shoulder has done absolutely nothing to reduce their shoulder. You perform your pre-procedure PSA Checklist, know that thisRead more

    • Sinusitis In Pediatrics?

      You’re working in pediatrics, when a mother comes in stating her 5 year old has sinusitis. He presents with fever, cough, runny nose, and some discomfort over where his frontal sinuses are. Does he haveRead more

    • Ring Removal

      Over the past week, we’ve had a strange uptick in number of patients presenting to the ER with rings stuck on their finger. This is a quick review on the options that you have regardingRead more