1.emergency airway management
DESCRIPTION
airway managementTRANSCRIPT
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Emergency
Airway Management
________________________________ Alamsyah Ambo Ala Husain
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CSL Coass BTLS BTCLS PPGD GELS ATLS ACLS PALS
Airway Breathing Circulation Disability Exposure
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Understand the basic anatomy of the Airway Understanding of basic airway maneuvers.
Chin Lift,
Jaw Thrust
Understanding of basic airway adjunct
Oropharyngeal Airway
Nasopharyngeal Airway
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Maintenance of adequate oxygenation (as measured by SatO2 or PaO2)
Maintenance of adequate ventilation (as measured by ETCO2 or PaCO2)
Protection of the airway from injury (avoiding aspiration, barotrauma, infection etc.)
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Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway
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Failure of oxygenation Failure of ventilation Failure to protect Impending obstruction
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Low FiO2 Failure of ventilation V/Q mismatch Diffusion abnormalities Anemia Low C.O. Increased tissue O2 consumption
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Brain CHI, Stroke, Raised ICP
Stem Stroke, Narcotics, Injury
Cord SCI, Degenerative disease
Nerve Peripheral Neuropathy
NMJ Myasthenia Gravis, Guillan-Barres, NMJBs
Muscle Myopathy
Thorax Burn Eschar, Rib fractures
Lungs Restrictive disease, Contusions
Abdomen Tense ascites, compartment syndrome
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Low or dropping GCS
GCS less than 8, intubate
Aspiration risk
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Expanding hematoma Deep space infection Epiglotitis / Bacterial tracheitis Angioedema / Allergic reaction Inhalation injury Eschar Foreign body Tumour Others.
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Photo Credit: Dr John Sherry II
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Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway
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Difficult Airway ?
RSI ?
Crash Airway
Difficult Airway
No
No
Yes
Yes
Crashing ?
Failed Airway
Fails
Fails
Fails
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7 P s Prepare = equipment Pretreat = drugs Position = sniffing position (if possible) Preoxygenate = 100 % pulse oxy (consider apneic oxygenation during direct laryngoscopy) [1]
Paralyze = drugs Placement = tube through cords Position = confirm with ETCO2 then CXR 1. Weingart, S and Levitan, R. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar; 59(3):165175
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Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway
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Difficult mask ventilation
Difficult laryngoscopy
Difficult tracheal intubation
Combinations of above
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Difficult mask ventilation; Predicting the difficulty (BOOTS); Bearded
Older (> 55 years)
Obese (BMI > 26 kg/m2)
Toothless
Snores
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Difficult laryngoscopy/intubation;
Predicting the difficulty (LEMON);
Look
Evaluate; 3-3-2
Mallampati score
Obstruction
Neck mobility
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Specific situations;
Trauma
Obesity
Pregnancy
Pediatrics
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Not a catastrophe if you cant see well Not even if you cant intubate
But, if you ALSO cant ventilate.
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Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway
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Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
Blind NTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
OR?
Topicalize
Sedate
Awake; Laryngoscope
Glidescope
Lighted Stylet
FOB
Help
Sedate
Topicalize
Brutane
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
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Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway
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Anticipated;
Best to get patient to ED/OR
BVM as bridge
Otherwise intubation
Dont burn bridges
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Unanticipated;
Can you ventilate??
Yes = time
No = trouble
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Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
Blind NTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
Transport
Observe
Help
Sedate
Topicalize
Brutane
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
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Difficult ventilation; 1. Head tilt/chin lift
2. Exaggerated Jaw thrust
3. Oral/nasal airways
4. Two handed/two person technique
5. Consider mask change
6. Ease up on cricoid pressure
7. Rule out FB
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Supraglottic Airway Devices
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Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
Blind NTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
Transport
Observe
Help
Sedate
Topicalize
Brutane
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
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Oxygenation NOT ventilation Use 14 g cannula with syringe attached, once
aspirating air, insert sheath and remove needle Connect a 3 way valve to sheath and to oxygen
tubing 15 L/min oxygen for 1 sec followed by 4 secs
expiration phase Approximately 45 mins to get definitive airway
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If your first intubation attempt fails ---think about what to do differently for attempt number two.