CRCST Self-Study Lesson Plan Lesson No. CRCST 144 (Technical Continuing Education - TCE)

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2 Lesson No. CRCST 144 (Technical Continuing Education - TCE) Sponsored by: by Carla McDermott, RN, CRCST, ACE Clinical Nurse III South Florida Baptist Hospital, Plant City, Fla. Rigid Laryngoscopes Learning Objectives 1. Identify the types of laryngoscopes used for endotracheal intubation 2. Explain the importance of having correctly-matched components in an intubation kit 3. Discuss the components of surgical laryngoscopes 4. List common accessories used in laryngoscopy procedures Laryngoscopes are COMMON INSTRUMENTS USED in many patient care areas; however, they become life-saving devices when they are used to establish an airway by placing an endotracheal tube into a patient s trachea (windpipe). Each style of laryngoscope has specific attachments and accessories, many of which are not interchangeable. Central Service (CS) technicians must know how to correctly group and assemble laryngoscope sets to ensure the surgeon will have the appropriate instrumentation to perform the scheduled procedure. This lesson will discuss the differences and similarities in rigid laryngoscopes and accessory instrumentation. Objective 1: Identify the types of laryngoscopes used for endotracheal intubation Once placed into a patient s trachea, endotracheal tubes are attached to an oxygen source and a ventilation device to enable the patient to breathe. This procedure is referred to as intubation, and intubation kits are located in code carts and selected critical care areas throughout hospital facilities. For example, pediatric code carts contain intubation kits with smaller handles and smaller blades (see Photo 1). The laryngoscope used for this purpose is referred to as a direct vision laryngoscope. The light source is a fiber-optic light tube built into the blade. Photo 1: Pediatric laryngoscope with blade sizes 0 thru 3. Note absence of color band. The handle is powered by battery, so it is lightweight and highly portable. The clinician performing the laryngoscopy looks directly through the hollow blade to visualize the vocal cords for placement of the endotracheal tube. This series of self-study lessons on CS topics was developed by the International Association of Healthcare Central Service Materiel Management (IAHCSMM). Purdue University s Extended Campus and IAHCSMM both offer grading opportunities. Earn Continuing Education Credits: Online: Visit for online grading at a nominal fee. By mail: For written grading of individual lessons, send completed quiz and $15 to: PEC Business Office, Purdue University, Stewart Center Room 110, 128 Memorial Mall, WestLafayette, IN Scoring: Each 20-question quiz graded online at or through Purdue University, with a passing score of 70% or higher, is worth two points (2 contact hours) toward CRCST re-certification (12 points). Subscription Series: From January 1 to June 30 each year, Purdue Extended Campus offers an annual mail-in or online self-study lesson subscription for $75 (six specific lessons worth 2 points each toward CRCST re-certification of 12 CE). Call for details. For More Information: IAHCSMM provides online grading service for any of the Lesson Plan varieties. Purdue University provides grading services solely for CRCST and CIS lessons. Direct any questions about online grading to IAHCSMM at Questions about written grading are answered by Purdue University at SEPTEMBER / OCTOBER 2015 Communiqué

3 Photo 2: Intubation kit handle with blades Photo 3: Miller (straight) blade and Macintosh (Mac; curved) blade Photo 4: Blade size is imprinted on the end of blade where it attaches to the handle Objective 2: Explain the importance of having correctly-matched components in an intubation kit Basic intubation kits generally include a handle, which is battery-operated (see Photo 2). The handle s finish is knurled to make it easier to grip. This feature that assists the physician creates a disadvantage for the Central Service (CS) personnel who must process it: the handle is more difficult to clean and disinfect. Also, battery-operated devices cannot be submerged in fluid, and this additionally complicates the cleaning task. CS technicians must know how to identify each style of handle and blade used in each type of intubation kit used in the facility. Typically, there is a color-coded band built into the handle and blade for easy identification. Once cleaned and disinfected in compliance with the intubation kit manufacturer s instructions, the battery is reinserted into the handle and tested. The battery testing process involves connecting a laryngoscope blade to the handle and engaging the blade by flipping it into the in-use position. The handle can be used if the light in the handle is clear and bright. When the battery test is completed, the blade can be disengaged from the handle and placed into the set. Laryngoscope handles come in a variety of sizes to accommodate the size of the patient: neonate/infant, youth, and adult. The handles can accommodate a wide variety of blades, and the two most common are the Miller (straight) blade, and the Macintosh (also called Mac), which is a curved blade (see Photo 3). The handle is also available in several grip sizes: short and fat, long and fat, short and slim, and long and slim. The choice should be limited to one for the basic intubation kit to reduce the chance for errors, and users can request other sizes for their work area. For example, anesthesiologists may request specific handle sizes to be stocked in their anesthesia carts. CS technicians must ensure that all the blades in the set match the handle. Some blade styles are not interchangeable, and a delay in life-saving intubation can occur if the user must find a matched functional blade and handle. In a worst case scenario, if none of the blades in the set match the handle, significant time can be wasted, and the patient s survival is jeopardized. As noted above, each style of blade also comes in a variety of sizes to accommodate the size of patient. The size of the blade is imprinted on the end of the blade where it attaches to the handle. (see Photo 4) A typical intubation kit contains one handle of the preferred size and one of each size blade (a range of 4 sizes) of the Miller and Mac blades, and a Magill forceps. Note: The Magill forceps is used, if needed, to advance the endotracheal tube through the vocal cords (see Photo 5). Intubation kits will include the Photo 5: Magill forceps size and variety of handle and blades selected by the Code Team Committee, which usually includes a team of anesthesiologists, emergency department physicians, and respiratory therapists. A CS representative should also be on the team to help determine the contents of a basic intubation kit that can be utilized by everyone. Cost will play some role in the selection of intubation kits, or they may become cost prohibitive. Specific areas, such as the emergency department and intensive care unit, can be stocked with other physicianpreferred blades at the user department s expense, if necessary; however, these blades should not be included in the basic set because the kit would be large, cumbersome and difficult to manage in an emergency. The basic intubation kit should be prepared so it is easy for users to manage. For example, the code team and CS representative might decide the kit should be in the form of a roll in which each item is held in place by a loop. Communiqué SEPTEMBER / OCTOBER 2015

4 Photo 6: A suspension bar holds the surgical laryngoscope in place Photo 7: Laryngoscopes are designed with a single or double light carrier Photo 8: Light cable The user can unroll the kit to easily see the contents and quickly perform the intubation. Another option might be an appropriately-labeled tackle box, so each item can be easily located. One final decision involves stocking endotracheal tubes. These tubes come in a wide variety of styles and sizes, and it would be impractical to include one of every kind in every code cart. Many departments stock their own endotracheal tubes to ensure they have the ones preferred by their own users. Depending on the facility s stock control method, CS personnel can replace used tubes on request, or they can be replaced in the same way as with other unit supplies. Remember that all of these factors require critical decisionmaking because a correctly stocked and functional intubation kit can save someone s life. Objective 3: Discuss the components of surgical laryngoscopes Surgical laryngoscopes are designed differently than basic intubation laryngoscopes. First, there are no interchangeable blades, and each scope is a complete instrument. These laryngoscopes also come in a variety of diameters and size lengths to accommodate patient sizes and the requirements of the planned procedure. Surgical laryngoscopes are most often used with a microscope. Once the laryngoscope is placed in the airway, it is held in position by a suspension bar centered on the patient s chest or mayo stand (see Photo 6). The microscope is positioned to allow the surgeon a greatly magnified view of the patient s airway and vocal cords. Procedures performed include biopsy of lesions, multiple biopsies to determine the margins of cancerous lesions, and removal of polyps or other benign lesions. Surgeon preference and planned procedure dictate the laryngoscope that will be selected. Light carriers are not interchangeable, so they must match the length of the specific scope. A light cable attaches to the light carrier which is secured in the laryngoscope to a light source. A laryngoscope may be designed with a single or double light carrier (see Photo 7). While many hospitals have a large assortment of laryngoscopes, light cables and light sources, these components are generally not interchangeable. Instead, both the end that attaches to the laryngoscope and the end that attaches to the light source require a specific connection (see Photo 8). A variety of connectors or adapters can be used to help make these connections possible, and they typically remain in the Ear Nose and Throat (ENT) cart in the operating suite; however, some may occasionally be left on a light cable and then sent to CS. The CS technician who receives the cable must recognize Photo 9: Cup biopsy forceps in various angles Photo 10: Scissor tips in various angles (cut-away) that the adapter is present and then conscientiously remove and return it to the operating suite. Much stress and frustration can be avoided if the proper connections are readily available when the surgeon wants to begin a laryngoscopic procedure. Objective 4: List common accessories used in laryngoscopy procedures Laryngoscopic procedures require a wide variety of accessory instruments. A laryngoscope of a specific length requires accessories of the same length. Accessories that are too long can be difficult to manage during the surgery, and instruments that are too short SEPTEMBER / OCTOBER 2015 Communiqué

5 frustrate the surgeon. Basic accessory instruments include suction tips, alligator forceps, cup biopsy forceps, grasping forceps, and scissors. A set of forceps may contain four alligator forceps with various angles, or four cupped forceps with various curves. A set of scissors may have four or five straight and curved scissors (see Photos 9 and 10). Different positions of each instrument s operating tip allow the surgeon to maneuver the patient s vocal cords and margins of the lesion. Micro instruments should be cleaned and then inspected under magnification each time they are processed to ensure they are clean and properly functioning for subsequent procedures. The importance of using magnification for this inspection cannot be over-emphasized. A nick on the cup biopsy forceps or burr on the scissors can cause unnecessary bleeding and traumatize the tissues. Some laryngoscopes and instruments have a non-reflective coating for use with a laser. This coating must be inspected for cracks and flaking. Damaged instruments must be tagged and removed from service. Other instruments are coated with insulation for use with an electrocautery unit. This insulation must be carefully inspected for integrity using magnification. Inspection errors can allow stray sparks in a patient s airway that can have life-threatening results. While these instruments are not highly sophisticated, they have specific matching needs. For example, instruments must be matched with accessories and cables, and accessories must be matched for style, length and tip size. Inspection with magnification to ensure proper functioning is also required. Special Acknowledgment: The author wishes to thank Dr. Francis De Rito for sharing his time and expertise in preparation of this lesson, and Kim Felker, CST, for her review and input. Resources International Association of Healthcare Central Service Materiel Management Central Service Technical Manual. Seventh Edition. Schultz R Inspecting Surgical Instruments: An Illustrated Guide. International Association of Healthcare Central Service Materiel Management. IAHCSMM acknowledges the assistance of the following two CS professionals who reviewed this quiz: Lisa Huber, BA, CRCST, ACE, FCS; Sterile Processing Manager, Anderson Hospital, Maryville, Ill. Paula VaNdiver, CRCST, CIS; Orthopedic Specialist, Anderson Hospital, Maryville, Ill. Advisory Committee for Self-Study Lessons Scott Davis, CMRP, CRCST, CHMMC Materials Manager, Surgical Services Las Vegas, Nev. Susan Klacik, ACE, CHL, CRCST, FCS CSS Manager, St. Elizabeth Health Center, Youngstown, Ohio Patti Koncur, CRCST, CHMMC, ACE Education Specialist, IAHCSMM Natalie LIND, FCS, CRCST, CHL Education Director, IAHCSMM Carol Petro, RN, BSN, CNOR, CRCST, CIS OR Educator and Sterile Processing Educator, Indiana University Health North Hospital, Carmel, Ind. Technical Editor Carla McDermott, RN, CRCST Clinical Nurse III, South Florida Baptist Hospital, Plant City, Fla. Series Writer/Editor Jack D. Ninemeier, Ph.D. Michigan State University East Lansing, Mich. In Conclusion CS technicians are tasked with providing specialty instrumentation that meets the needs of the surgeon, Operating Room team and patient. Laryngoscopes are specialty instruments that can only be effectively managed if CS technicians participate in carefully-planned education sessions to learn how these expensive instruments should be cleaned, processed, and returned to the proper set or location. WANT TO BE AN AUTHOR? IAHCSMM is seeking volunteers to write or contribute information for our CRCST Self-Study Lessons. Doing so is a great way to contribute to your own professional development, to your Association, and to your Central Service department peers. IAHCSMM will provide guidelines and help you with the lesson to ensure it will be an enjoyable process. For more information, please contact Julie Williamson (julie@iahcsmm.org). Communiqué SEPTEMBER / OCTOBER 2015