In the hotter months in Australia, our hollow blue Frova Introducers are susceptible to softening after being left lying in the hot sun. It’s hard to tell what the problem with this bougie is on the video but the team report a very soft supple bougie. 

This magnified video view showing the target site for blade tip demonstrates our targeted anatomical landmarks – if we place our blade tip into the vallecula it is this ligament, the hyoepiglottic ligament, (looking like a frenulum) that we control to lift the epiglottis. 

Massive gastric regurgitation obscuring laryngeal view and causing pulmonary aspiration seems much more likely in cardiac arrest resuscitations than our usual prehospital RSIs. This paediatric out-of-hospital cardiac arrest patient regurgitated during bougie placement. Drilling actions in response to fluid regurgitation is worthwhile, especially in smaller mouths.  

In this case, the laryngoscope was inadvertently placed beyond the larynx, which can be common using a Mac4 blade for allcomers. Gently/slowly allowing the blade tip to withdraw gives time to see the larynx falling from above. Repositioning into the vallecula is an option if there’s any difficulty directing the bougie to the cords. This technique - of ‘deep midline, lift & withdraw’ - is an option when no landmarks are found on initial laryngoscopy. 

This video starts with the bougie between the cords, in the trachea. We’re used to issues with our tube tips catching on arytenoids and other laryngeal structures but this one grabs the epiglottis itself. The gap between ETT tip and bougie on railroading can catch on just about anything – so any resistance to slide needs to be considered as a catch. To fix: withdraw the ETT slightly on the bougie (or with the bougie) then rotate slightly to change approach of tip.