Low-Cost Portable Suction-Assisted Laryngoscopy Airway Decontamination (SALAD) Simulator for Dynamic Emesis

: Audience: The suction-assisted laryngoscopy airway decontamination (SALAD) simulator is designed to instruct emergency medicine residents, paramedic students, and students interested in emergency medicine. Introduction: The ability to establish an adequate airway by intubation is a core procedural skill taught throughout emergency medicine training. Frequently, active emesis, massive regurgitation or hemorrhage during endotracheal tube placement can obstruct visualization of the larynx, increase risk of aspiration and complicate airway management. 1 Consequently, providers are expected to quickly stabilize a patient’s airway during episodes of airway contamination to reduce complications and improve outcomes. Suction-assisted laryngoscopy airway decontamination (SALAD) is a systematic method that uses suction and the laryngoscope to clear the airway and visualize landmarks for placement of the endotracheal (ET) tube. Emergency medicine resident physicians are expected to perform a minimum of thirty-five intubations throughout training to become proficient in the procedure; 2 however, simulated intubation exercises that replicate dynamic fluid contamination from emesis or blood are often expensive or not utilized. 3 This SALAD model was created by Dr. DuCanto to economically replicate the airway of an actively vomiting patient requiring endotracheal tube placement. The dynamic trainer airway airway, emesis, hemorrhage, hemorrhaging, oropharynx, airway contaminant, obstructed airway,

Section break contraindications associated with intubation of a vomiting or hemorrhaging patient. 2) Work with colleagues to effectively stabilize a patient who is actively vomiting or bleeding during airway management. 3) Competently perform intubation in the acute setting of visual obstruction from active emesis, hemorrhage, or massive regurgitation. 4) Increase speed and dexterity of intubation by applying the SALAD method when fluid obstructs visualization of the larynx.
Methods: A dynamic, high fidelity simulation trainer will be used to recreate the scenario of a patient actively vomiting or bleeding during emergent airway intubation. Polyvinyl chloride (PVC) tubing, a hand-operated water pump, an airway management trainer, and an LTVÒ vent connector are used to create a low-cost circuit that models active emesis. BARFume puke spray, Laerdal stomach contents, and Campbell's soup were used to create artificial vomitus. Residents will use suction and the laryngoscope to practice intubating on the airway management trainer while liquid is pumped to simulate visual obstruction from fluid contents.

Linked objectives and methods:
Practicing SALAD intubation on a dynamic airway model is ideal for learners to become familiar with using suction and the laryngoscope prior to managing the airway of live patients. Learners are expected to review pre-reading material and participate in discussion of the SALAD technique in order to demonstrate understanding and indications of the procedure (objective 1). Learners will then form teams to manage a decompensating patient by applying the SALAD intubation technique to establish a secure airway on the dynamic model (objective 2). Faculty will observe and provide feedback to the participants throughout the session (objective 3). Using a stopwatch, one team member will record the elapsed time required to intubate the patient as a metric to emphasize the importance of quick intubation in the setting of airway contamination (objective 4). Learners and faculty will then debrief the session, exchange feedback and reflect on difficulties associated with SALAD intubation (objective 2). This format was selected to realistically replicate the scenario of intubation while simultaneously creating an environment where learners can ask questions and demonstrate competency in the procedure.

Implementation Methods:
In groups of four learners will spend: • 5-10 minutes reviewing intubation protocol and the SALAD technique. • 25-30 minutes using the innovation.

Objectives:
The economic and dynamic SALAD innovation recreates an actively vomiting patient and replicates visual obstruction from fluid contents during airway management.
By the end of the session, learners are expected to: 1. Discuss the risks, benefits, indications and contraindications associated with intubation of a vomiting or hemorrhaging patient. 2. Effectively stabilize a patient who is actively vomiting or bleeding during airway management. 3. Competently perform intubation in the acute setting of visual obstruction from active emesis, hemorrhage, or massive regurgitation.

Increase speed and dexterity of intubation by
applying the SALAD method when fluid obstructs visualization of the larynx. Remaining learners are expected to actively engage in the simulation, assist with airway stabilization if appropriate, provide feedback, and ask questions.

USER GUIDE
Times from the stop watch will be recorded to assess competency of speed. The instructor will provide feedback and assess competency of the intubation technique.

Detailed methods to construct this innovation:
Assembly: 1. Take 5' tubing and cut a "v" shape ~3/4" deep and ~½: wide. When cutting width, the sides of the cut pressed together should reduce the outside tubing diameter to approximate the internal diameter of the vent adapter 2. Firmly insert the cut end into the vent tubing connector so that the entire cut is inside the connector (otherwise it will leak).
3. Insert the assembled end piece into the esophagus port on the mannequin.
4. Attach the other end of 5' tubing to the outflow port of the hand-pump 5. Connect an end of the 10' tubing to the inflow port of the pump. The other end will be placed into the container you'll be drawing "emesis' from (ie, 5gal bucket, 1gal jugs). This will slide over the barbs and ~3/4" of the base of the pump, which may require a twisting motion to accomplish.
Assembled Product:

Results and tips for successful implementation:
The SALAD simulation model was used to supplement a didactic lecture series on advanced airway management for resident and medical student learners. The model was tested on twentytwo learners during protected education time. The breakdown of learners included: fifteen emergency medicine residents, one off-service resident, one physician assistant fellow, and five medical students. A post-session survey using a five-point Likert scale of strongly agree (score of 5) to strongly disagree (score of 1) was administered to evaluate the utility and success of the SALAD simulation model. All twenty-two participants responded to the survey directly following the session (100% response rate). 90.9% of learners strongly agreed and 9.1% agreed that the simulation model increased their familiarity