So You Want to Tomahawk Somebody?

The Tomahawk Approach to the Airway

If you took a listen to our last podcast or inferred from our most recent post, the "challenging airway" that was described was managed by way of a tomahawk intubation.  As we discussed in the podcast, there were a number of different ways we could have elected to manage that patient's airway including intubation from the back of the stretcher with the patient seated upright, awake fiberoptic intubation (both nasotracheal and oropharyngeal with the assistance of a Williams airway), tomahawk intubation, or, as was suggested by one of the residents (nice suggestion Dr. Cousar) after our simulation (on the same case), through a bronch adapter hooked to a LMA...

Anybody tried set-up like this for intubating through LMA (using bronch adapter on ett to give breaths while scope) pic.twitter.com/rfQgXaZYCQ

— Mike Steuerwald (@MikeSteuerwald) April 12, 2014

For the purposes of this post, I wanted to focus on some of the nuances of performing a tomahawk intubation so you can reliably keep in your airway armamentarium.  (A special thanks to Dr. Steven Carleton for providing feedback and pointing out several of these tips)

What do you mean "Tomahawk Intubation"

Basically this means we are intubating from the front of the patient with the patient in the seated position.**  Thus it is ideal for those patients who you do not want to lay flat (think pulmonary edema, obese, tenuous oxygen saturations, or dynamic airway obstruction).  This is most often (and most easily) done with some form of video laryngoscope.

*As an added bonus, keeping the patient upright lets any airway secretions drain away from the camera at the tip of the video laryngoscope

What are the tricks to doing this well?

Know that the patient's head will be floppy after they have been sedated (think newborn baby-level head control).  You will need to enlisted the help of a colleague to stabilize the head (as seen in the pic above)

You need to hold the laryngoscope in your right hand (opposite from when you are intubating from above).  If you don't, you will have your hands crossed and it will be more challenging to pass the tube through the glottic opening

Hands crossed = biomechanically unhappy

Ahh... much better

It may be easier to perform this procedure while using a video laryngoscope with a channel (i.e King Vision with a channel or an AirTraq).  The reason for this is having the tube anchored to the laryngoscope allows you to manipulate and aim the laryngoscope with your dominant hand (assuming your are right handed).  Once you have the glottic opening centered into the field of view, you can then easily pass the tube with your left hand.

King Vision with a Channel

Center glottic opening on screen and pass the tube

For fiberoptic intubations when you are intubating facing the patient, it is best to position their head at the level of your own head.  That is not necessarily the case with the tomahawk intubation.  If you position their head at the level of your head, you will not have as good of control of the ET tube as you try to pass it.  When the patient is lower than you you may potentially be better able to finely manipulate the ET tube into and through the glottic opening.

Patient Below = Better Control

Less control for tube passage if the patient is on the same level

Finally, as a point that applies to all intubations with a video device with a hyper-curved blade (i.e. the CMac with the D blade), you need to avoid placing it too close to the glottic opening (either by using like a Miller or by simply angling the camera closer to the glottic opening).  Epiglottoscopy should always be the first step of placement of the laryngoscope with direct visualization guiding placement into the vallecula.   Then look at the screen ensuring a "cheap seats" view of the glottic opening with part of the epiglottis visible in the screen.  Failure to do so will cause the ET tube, bougie, or whatever else you attempt to pass to be pushed posteriorly into the esophagus by the curve of the laryngoscope blade.  It is exceptionally easy to get "too deep" with the blade when performing the tomahawk approach to the intubation. (Check out the 4 Secrets to Video Laryngoscopy by Dr. Levitan published in EP monthly for more info on this).

Too Deep - Unable to pass tube

Correct placement of blade gives you a "cheap seats" view of the glottic opening