On a warm Sunday afternoon in July, you and your partner respond to a residence for a reported pediatric drowning. Arriving on scene, you find sheriff's deputies performing CPR on a 3-year-old girl. A hysterical family member tells you the little girl went missing from her grandmother's birthday party about 20 minutes ago, while they were opening presents, and was found in the backyard pool. She was pulled from the pool by her father, who began CPR.
As your partner works on establishing an intraosseous line and deputies pre-oxygenate the patient, you set up your equipment for endotracheal intubation. As you attempt to pass the ET tube, you lose direct sight of the epiglottis and vocal cords, and a second attempt yields the same result. Your partner, who has placed the IO line, says, "Bougie it!" This time, instead of attempting to place the ET tube, you attempt intubation with the gum elastic bougie, which does not obstruct your view, and you are able to pass it between the vocal cords without difficulty. Your partner then threads the 4.5 mm ET tube onto the end of the bougie and you slide it through the vocal cords to the appropriate depth, at which time your partner removes the bougie. You then assess placement and secure the ET tube according to your guidelines.
Securing the Airway
Securing a definitive airway in the prehospital environment is often difficult at best. That said, ET intubation continues to be the gold standard for securing a definitive airway for paramedics and, in some states, by EMT-Intermediates, although airway management can often be accomplished using less invasive procedures and still allow adequate ventilation and oxygenation without ET intubation. There are times when the only way to adequately ventilate and oxygenate a patient is with an ET tube. Patients with macerated tongues, vomitus, blood and foreign debris in the airway, to name a few, may significantly benefit from ET intubation and are often the most challenging airways to secure.1,2 For less obvious difficult airways, a quick, simple pre-ET intubation airway evaluation (see Figure 1) can assist in determining whether the patient may present with a difficult airway.3 Both the obvious and not so obvious patients with difficult airways often fall under what the American Society of Anesthesiologists call "cannot intubate and cannot ventilate"4 airways, which can lead to patient compromise such as aspiration, trauma to the airway and potentially death. One tool utilized by anesthesiologists for decades to facilitate ET intubation in these types of patients is the gum elastic bougie.
Overview and History
The gum elastic bougie (GEB), often just referred to as the bougie by EMS clinicians, is an adjunct for difficult ET intubations when the laryngeal inlet cannot be completely visualized.5 Research by anesthesiologists, emergency physicians and EMS clinicians has demonstrated significantly improved ET intubation success rates and decreased time required for intubation when using a bougie versus a traditional stylet and ET tube.6 This is attributed to the smaller diameter of the bougie versus the diameter of an ET tube. The bougie was first used by Robert Macintosh in 1943 when he encountered difficulty visualizing the vocal cords during ET intubation.7 The term bougie originally described any flexible, slender, dilator-type device that was inserted into any body orifice for examination or dilation. The term was also used for wax candles, as bougie is an old French word for fine wax, originating from Bejaia (bougie), a city in northern Algeria.8 The current gum elastic bougies are not gummy or elastic, but rigid. The original reusable version is a fiberglass core covered in a beige resin and measuring 60 cm in length, with the distal tip having a 38° bend. Commonly used in the United Kingdom since the 1950s, it gained popularity with anesthesiologists in the United States about 30 years ago, and roughly 10 years ago made its appearance in the EMS community.9 It may also be referred to as the gum bougie, tracheal tube introducer or the Eschmann stylet. While it was originally manufactured by Portex, there are now many manufacturers of a bougie-like device, which comes in both reusable and disposable versions.