Ready are you? What know you of ready? ~ Yoda







The Standard SALAD Approach



The SALAD technique (Suction Assisted Laryngoscopy and Airway Decontamination) invented by Jim DuCanto has revolutionised the way we approach contaminated airways1.



Designed to reduce the risk of aspiration and facilitate unobscured laryngoscopy, the operator leads with an appropriate suction catheter, keeping their laryngoscope blade (and video lens) ‘high and dry’. The catheter tip is then ‘parked’ in the hypopharynx/upper oesophagus.



The next move is genius – without moving the suction catheter tip, the body of the catheter is moved round so that it can be held by the operator’s laryngoscope (left) hand, between the palm and the laryngoscope. This frees up the right hand for bougie and tube insertion via a clear route to the larynx while the suction catheter continues to collect the regurgitant fluid. This works great for stomach contents and upper gastrointestinal haemorrhage.













Non-Gastric Contaminant Sources



However, not all nastiness arises from the GI tract. In my emergency medicine and prehospital critical care practice, we intubate patients with maxillofacial trauma, massive epistaxis, post-tonsillectomy bleeding, drowning, acute pulmonary oedema, and massive haemoptysis.



This led me to consider that there are three general trajectories by which contaminant fluid can reach the pharynx and impede laryngoscopy: (1) from above, ie. mouth and nose; (2) from below, via the GI tract; and (3) from below, via the respiratory tract. The SALAD technique may need to be modified or supplemented depending on the trajectory.



I contacted Jim last year about this to get his thoughts:







Not surprisingly he made perfect sense – park (even bury) the catheter in the oesophagus when the GI tract is the problem, otherwise position it above and to the left side of the larynx.



Note that Jim mentions pulmonary oedema and reminds us of the bougie-through-the-suction-catheter trick; more on that below.



Let’s consider the three trajectories and what our options are:



Trajectory 1 – Stuff coming UP – from the GI Tract



Think haematemesis, small bowel obstruction, alcohol and kebab intoxication, ozempic use?







Here the classic SALAD positioning of the suction catheter in the hypopharynx/proximal oesophagus makes perfect sense







Modifications or supplemental actions:



It can be prudent to insert a gastric tube and decompress the stomach prior to intubation in high risk patients if conditions allow.



During laryngoscopy, if the bad stuff just keeps on coming (think aorto-enteric fistula), consider deliberately intubating the oesophagus first with a tracheal tube and using that to divert the flow to a suction source, and use a second suction to decontaminate the airway and clear a path for laryngoscopy.



Trajectory 2 – Stuff coming UP – from the Respiratory Tract



This can result from haemoptysis or pulmonary oedema or drowning







This can be a major challenge. Particularly in pulmonary oedema, since suction just begets MORE pulmonary oedema, and you’ll be there all day trying to clear it.



What the patient needs is urgent tracheal intubation with a cuffed tube followed by positive pressure, including PEEP



Check out this intubation of a drowning case in which the double SALAD nightmare of gastric regurgitation AND frothy tracheal fluid is present. Note how the froth won’t stop until there is positive pressure ventilation via a cuffed tracheal tube:







Modifications or supplemental actions:



The trick here is to aim your bougie to the source of the froth when it is clear that it is of pulmonary origin.



One clever option is to place the suction catheter through the cords, disconnect the suction tubing from the catheter, and then advance the bougie through the suction catheter2. The catheter is then removed and a tracheal tube can be inserted over the bougie. Note that this is only described with the dedicated resuscitation suction catheter (DuCanto catheter).







Trajectory 3 – Stuff coming DOWN – from the Upper Respiratory Tract







Here the contamination is usually a bleeding source, for example maxillo-facial haemorrhage, epistaxis, post-tonsillectomy bleed.



The suction is used to navigate to the larynx; it need not be parked deeply in the hypopharynx because the source is not from the oesophagus. This video is from a patient with severe epistaxis (there was another indication for intubation).









Modifications or supplemental actions:



Consider local haemorrhage control measures (eg. balloon tamponade for epistaxis).







Surprise trajectory 4 – In Situ Spontaneous Airway Contamination



Sometimes weird stuff just happens. In this video (courtesy of Sydney HEMS), an epiglottis abscess bursts during laryngoscopy, giving rise to unanticipated pus contamination:













Training



All serious critical care teams should train for airway contamination scenarios. Airway manikins can be modified using inexpensive parts available from DIY stores. Here’s one I built with my friend Dr Luca Ünlü:









An even less expensive version has been described using materials readily available in the operating theatre or emergency department3.



While most simulators replicate Trajectory 1 – stuff coming up from the GI Tract, you can be imaginative. To replicate the challenging drowned baby scenario, Luca and I built an infant pulmonary oedema trainer:













Summary



Jim DuCanto’s SALAD system has changed the game in critical care airway management. Teams now have a plan and a way of training for contaminated airway situations.



Consider that not all contaminated airway scenarios are identical. Remember the three trajectories of how the contaminant gets there, and how you might have to adjust your technique accordingly and add supplemental measures.



And in-situ spontaneous contamination can occur too if you’re lucky enough to see an epiglottic abscess erupt!







References



Root CW, Mitchell OJL, Brown R, et al. Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management. Resusc Plus. 2020 May 21;1-2:100005. Cochran-Caggiano N, Holliday J, Howard C. A Novel Intubation Technique: Bougie Introduction Via Ducanto Suction Catheter. J Emerg Med. 2024 Feb;66(2):221-224. Warburton D, Hartopp A. Creating an easy to construct, low-cost aspiration simulator for airway training. International Journal of Healthcare Simulation 2022;2(Suppl 1):A28
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5-6 December 2024, Broadway House, London







Case based discussions that cover best practice in airway management, ventilation, shock management and haemodynamic support, neuroprotection, sepsis, trauma and haemorrhage PLUS how to make it happen! For the first time Cliff is adding extensive content on leadership, communication, and human factors.



FULL PROGRAM AND REGISTRATION HERE



Note This is an IN-PERSON, TWO-DAY event. There is no option to attend virtually. Participants are expected to attend both days. No refunds will be given if only one day is attended.

After 19 years of teaching everything Dr Cliff Reid wishes someone told him when he was training in emergency medicine and intensive care in one day, he’s finally extended it to two days to allow more in depth discussion of clinical AND non-technical factors. It’s not just about what to do, but how to make things happen when the system is conspiring against you!








…

Tues 24 September 2024, Broadway House, London



This is a one day run through of how I think every aspect of resuscitation and critical care in the emergency department should be done.



It combines my experience of more than twenty years as a specialist in emergency medicine, critical care, and retrieval medicine with the most up to date information from the latest literature.



The format is classroom case-based discussion, with key memorable concepts shared in a way that can make a lot of participants thing differently about the clinical stuff they see every day.



Yes, it’s impossible to cover everything in one day when the venue kicks us out at 5pm. But it is SO much fun trying. And we go to the pub after for anyone that wants to keep the conversation going.



Get tickets here








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There has been an exponential rise in COVID-19 cases. There is no doubt we’re feeling the effects of that all over the world. Many people, especially it seems, the lay public and politicians, have a hard time understanding the meaning of ‘exponential’.



The scariness of exponential growth shown here with E.coli
Image by Stewart EJ, Madden R, Paul G, Taddei F (2005) / CC BY-SA



But can exponential rise continue? If cases double every 3-4 days, then based on today’s figures from the Johns Hopkins Dashboard (1st April) by May 6 there will over 8.7 billion people infected, which is more than everyone on the planet, and clearly impossible.



This means the rise must tail off eventually. In fact, the more people there are who are infected, the harder it is to find someone to infect with the virus who hasn’t already got it. Also, spread should be limited by the social distancing and other measures (such as handwashing).



This actually gives rise to a LOGISTIC curve, rather than an EXPONENTIAL curve. This is an S-shaped curve that describes population growth (in both viruses and people) as well as other phenomena in economics and science(1).



Attribution: Qef / Public domain



Notice in the above curve the mid-point marked 0.5. This is the inflection point when the rate of increase in cases stabilises before declining. Specifically, the ‘Growth Factor’, or number of new cases in one day divided by the number of new cases the previous day, equals 1. Note at this point cases are still increasing – the virus is still spreading – but it’s not accelerating, and therefore no longer on an exponential trajectory.



Image from ‘Exponential growth and epidemics’ by 3Blue1Brown



This isn’t the only model to describe pandemics and none is perfect(2). We still can’t predict what will happen with SARS-CoV-2 and we absolutely need to continue to enforce strict containment measures. But having a basic understanding of the data gives us ways to visualise it that allow comparisons, and show which countries have ‘fallen off’ the exponential rise curve.



Logarithmic graph by Aatish Bhatia in collaboration with Minute Physics – see https://aatishb.com/covidtrends for up-to-date animated graph



Since in most places, we are still on the exponential part of the curve, it is imperative to educate as many people as we can on the benefits of strict isolation and hygiene measures:



Great infographic by @GaryWarshaw and @SignerLab




The best brief explanation of the above, which prompted me to write this brief post, is by the brilliant minutephysics



Take a few minutes to watch the video below:







Please note all the caveats at the end of the video. And one final one – I’m not an epidemiologist or mathematician. I’ve just been wrestling with what the endpoint of exponential rise would be and found these resources helpful.



References



1. https://www.nctm.org/Classroom-Resources/Illuminations/Interactives/Pandemics-How-Are-Viruses-Spread/



2. Yang W, Zhang D, Peng L, Zhuge C, arXiv LHAP, 2020. Rational evaluation of various epidemic models based on the COVID-19 data of China. arxivorg
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One of my nursing colleagues was telling a story the other day about one of the first resuscitations we did together in the ED several years ago. It demonstrates the principle of establishing control of a sub-optimally coordinated team by using some form of attention grabber. She kindly agreed to write down her recollection for me to share here:
I have finally found 2 minutes to sit down and write you the story I was telling you about the other week….
We were in the middle of a resus in the ED, it was chaotic, loud and messy.
I remember you calling out in a commanding voice for everyone to stop (can’t recall what you actually said) but when we all looked up and fell silent you lifted up one leg, let a rather loud large fart out and then very calmly proceeded to take control of the situation. Everyone was so stunned, and slightly amused that the whole situation just settled right down and we all cracked on with the resus in a much more organised fashion.
I don’t know if you know I own a first aid training company. I tell this story when I am teaching. I explain to people that an emergency situation can be chaotic and stressful and someone has to take control. Sometimes you need to take a second to get a grip of yourself and others before you can be of any help to the person in need.
By telling your story it makes people realise you can stop for a second to gather yourself, take stock of what is needed then crack on. Sometimes it takes extreme measures such as dropping a fart to get people to get back on track.
You have given me many stories over the years but the fart one has got the most traction so far.
See you at work
 
 


I accept that some people may find this offensive or consider it inappropriate or unprofessional. Please consider:



All mammals produce flatus.Holding on to flatus can be uncomfortable and can distract a resuscitation team leader, potentially adversely affecting outcome.The performance had its desired effect, helping the resuscitation.The patient was intubated and therefore not at olfactory riskC’mon jeez it was just a fart
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