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You do perfect patient positioning.

You open the mouth.

A beautiful, gentle, stepwise insertion of the laryngoscope allows you to get the tip of your video Mac into the valeculla.

And you see...

Nothing!

What now?

Abandon the attempt--nope!

Use the Kovacs Kata

The Kovacs Kata is dedicated to my friend and airway Guru, George Kovacs.

George had described his EVLI approach to laryngoscopy as a kata (see EMCrit 236). That struck me more as mental rehearsal however. A kata in my martial arts experience was always a fight against multiple imaginary opponents. The way I taught the kata for rescuing a failed laryngoscopy is a fight against 5 opponents of success using 5 techniques:

1. Neck

Neck refers to external laryngeal manipulation (ELM).

* Bimanual Laryngoscopy on LitFL

* Levitan Study on BiManual/ELM

2. Head

If you do not have a good view with your pre-intubation positioning, keep lifting and if necessary, flex the head.

* Kovacs Head Lift Video

* Keith Greenland on Why this Works

* Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy

3. Hands

If you are not strong enough to lift the patient's head off of the bed with one hand, use two. Then maintain the lift with one hand, aided by locking the left elbow against your body.

4. Scoop

If you have an epiglottis that you can't see past, despite the optimizations above, then just lift it with the Mac, i.e. use the Mac as a Miller.

* Levitan Article on Managing an Omega Epiglottis including the Scoop Maneuver

5. Pull Back

This one is for the hyperangulated blade. You have a great view--you just can't get the tube to go into the glottis.

* Why too close is too bad

* George on Hyperangulated Problem-Solving

* Levitan on HyperAngulated Blade Use and the Kovacs Sign

Additional Attributions

* Full Kata Video

Now on to the Vodcast...