403:(RCTs) of SALAD versus conventional emergency airway management strategies in real patients. The sporadic incidence of massive airway contamination during intubation attempts mean that an RCT of SALAD versus usual care is likely to be unfeasible to conduct. However, there is a growing body of lower quality evidence (simulation studies, and studies utilising observational data from patients) that are encouraging in terms of increasing clinician's confidence in managing severely contaminated airways and improving intubation success rates as well as time to successful intubation in cases of significant airway soiling. Two case reports in the peer-reviewed literature to date (Summer 2021) have described the SALAD technique as instrumental for emergency airway management in critically ill patients.
103:(OHCA), vomiting and regurgitation have a reported incidence of 20–30%. The traditional approach to the contaminated airway involves suctioning the airway and repositioning the patient, which can effectively manage airway soiling in many, but not all, cases. However, traditional airway management education has not included the integration of a simultaneous suctioning and airway decontamination skill set as a technique that can be deployed in the setting of large volume contamination and clinicians frequently underestimate the importance of suction as part of airway management.
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SALAD was developed as a simulation exercise in 2014, by a US anaesthetist Dr. Jim DuCanto. It was subsequently introduced into several US academic emergency medicine departments, culminating in its presentation at the 2015 Social Media and
Critical Care Conference (SMACC). This raised the profile of
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Hold the suction catheter (wide-bore, rigid) in a clenched-fisted right hand, with the distal end of the catheter pointing caudad and posterior, to enable manipulation of the tongue and mandible as required. The curve of the rigid suction catheter should mirror the curve of the structures of the
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procedures, however, many medical educators who wish to disseminate information regarding new and effective techniques to manage contaminated airways have sought a template upon which to build their simulation instructions, and this guide to the technique simply serves to provide that template.
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The following description of the SALAD Technique is intended to provide a template for medical educators to practice this technique in a medical simulation setting, and does not constitute medical advice. Knowledge (XXG) does not generally approve of articles that serve as guides to perform
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Root, Christopher W.; Mitchell, Oscar J. L.; Brown, Russ; Evers, Christopher B.; Boyle, Jess; Griffin, Cynthia; West, Frances Mae; Gomm, Edward; Miles, Edward; McGuire, Barry; Swaminathan, Anand; St George, Jonathan; Horowitz, James M.; DuCanto, James (2020-03-01).
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to enable identification of relevant anatomical structure (posterior portion of tongue, epiglottis, vallecular and laryngeal outlet) and follow with the laryngoscope (particularly important with video laryngoscopes to avoid contaminating the
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the technique internationally. Following its introduction to the international community at SMACC, multiple medical educators introduced the technique in their own institutions and services across
Australasia, Europe and Asia.
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In order to facilitate placement of the tracheal tube, the suction catheter is moved across to the left side of the mouth and the suction catheter 'parked' in the top of the oesophagus to provide continuous
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An example of a SALAD training setup. An advanced airway mannikin has been modified with standard garden hose and fixings to connect the oesophagus to a bilge pump situated in a reservoir of artificial
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attempt. This can be achieved either by sliding the catheter under the laryngoscope blade, or by briefly removing the catheter and inserting it to the left of the laryngoscope blade.
1049:"A pilot study on using Suction-Assisted Laryngoscopy Airway Decontamination techniques to assist endotracheal intubation by GlideScope® in a manikin simulating massive hematemesis"
1090:"Impact of Suction-Assisted Laryngoscopy and Airway Decontamination Technique on Intubation Quality Metrics in a Helicopter Emergency Medical Service: An Educational Intervention"
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Simons, Reed W.; Rea, Thomas D.; Becker, Linda J.; Eisenberg, Mickey S. (2007-09-01). "The incidence and significance of emesis associated with out-of-hospital cardiac arrest".
1151:"Successful Endotracheal Intubation Using Suction-Assisted Laryngoscopy Assisted Decontamination Technique and a Head-Down Tilt Position during Massive Regurgitation"
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Insert the index finger of the right hand into the right-hand side of the oropharynx to create a 'channel' for tracheal tube delivery (known as the SALAD poke).
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This has led to the development of the SALAD technique, and the creation of modified airway manikins to allow for practice in these techniques.
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933:"Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics (SATIATED): a randomised controlled manikin study"
992:"The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation"
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down the tracheal tube with a flexible suction catheter prior to ventilation to remove any residual contaminant prior to ventilation.
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Voss, Sarah; Rhys, Megan; Coates, David; Greenwood, Rosemary; Nolan, Jerry P.; Thomas, Matthew; Benger, Jonathan (2014-12-01).
813:"Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System"
428:"Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management"
40:
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698:"The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation"
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Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D. (2014-06-01).
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Lin, Li-Wei; Huang, Chi-Chieh; Ong, Jiann Ruey; Chong, Chee-Fah; Wu, Nai-Yuan; Hung, Shih-Wen (2019-11-15).
880:"Suction-Assisted Laryngoscopy-Assisted Decontamination (SALAD) simulator for difficult airway management"
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Della Vella, Carmine; Thompson, Ryan J.; Serrano, Karen; Riess, Matthias L.; Ducanto, James (2018-12-01).
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Ko, Shing; Wong, Oi Fung; Wong, Ching Hin Kevin; Ma, Hing Man; Lit, Chau Hung Albert (2019-11-04).
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Inflate the cuff on the tracheal tube to prevent further contamination of the lower airway.
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is incremental step-wise approach to the management of a massively contaminated airway.
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Jensen, Matthew; Barmaan, Benjamin; Orndahl, Christine M.; Louka, Amir (2020-03-01).
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Frantz, Eric; Sarani, Nima; Pirotte, Andrew; Jackson, Bradley S. (2021-01-14).
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641:"Crisis management during anaesthesia: regurgitation, vomiting, and aspiration"
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Kluger, M. T.; Visvanathan, T.; Myburgh, J. A.; Westhorpe, R. N. (2005-06-01).
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Choi, Insung; Choi, Young Woong; Han, Sang Hyuk; Lee, Ji Heui (2020-12-30).
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531:"How do paramedics manage the airway during out of hospital cardiac arrest?"
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Emergency airway management is often complicated by the presence of blood,
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or other contaminants in the airway. For example, in out-of-hospital
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Kozak, Richard J.; Ginther, Bret E.; Bean, Walter S. (1997-01-01).
594:"Aspiration under anaesthesia: risk assessment and decision-making"
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success (e.g. external auditory meatus level with sternal notch).
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Optimally position the patient to maximise the probability of
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DuCanto, James; Serrano, Karen; Thompson, Ryan (2017-01-19).
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Continuing
Education in Anaesthesia, Critical Care & Pain
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device, but the principle for motorised suction is the same.
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Suction
Assisted Laryngoscopy Airway Decontamination (SALAD)
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The SALAD technique consists of the following steps:
592:Robinson, Michael; Davidson, Andrew (2014-08-01).
387:Note that these images are using a hand-operated
931:Pilbery, Richard; Teare, M. Dawn (2019-06-01).
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68:Learn how and when to remove this message
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45:Knowledge (XXG) is not a "how to" guide.
1053:Hong Kong Journal of Emergency Medicine
884:Trends in Anaesthesia and Critical Care
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817:Western Journal of Emergency Medicine
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547:10.1016/j.resuscitation.2014.09.008
500:10.1016/j.resuscitation.2007.01.038
399:To date, there have been no large,
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1208:"Woman in respiratory distress"
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1155:Soonchunhyang Medical Science
830:10.5811/westjem.2016.9.30891
714:10.1097/CCM.0000000000000213
445:10.1016/j.resplu.2020.100005
401:randomised controlled trials
217:during the remainder of the
1008:10.1097/MD.0000000000017898
237:Catheter moved to left-side
43:. The specific problem is:
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896:10.1016/j.tacc.2018.09.060
759:Prehospital Emergency Care
241:'parked' in the oesophagus
239:of the patient's mouth and
39:to meet Knowledge (XXG)'s
1106:10.1016/j.amj.2019.10.005
937:British Paramedic Journal
771:10.1080/10903129708958795
1066:10.1177/1024907919884206
657:10.1136/qshc.2002.004259
645:BMJ Quality & Safety
611:10.1093/bjaceaccp/mkt053
702:Critical Care Medicine
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50:improve this article
1168:10.15746/sms.20.019
1094:Air Medical Journal
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625:2020-10-25
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438:: 100005.
407:References
219:intubation
171:Lead with
148:intubation
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