airway managment 2
TRANSCRIPT
In The Name Of GodIn The Name Of God
Airway Airway ManagementManagement
IntroductionIntroduction
Directed ByDirected By::Behdad Bazargani Behdad Bazargani
M.DM.D..AnesthesiologistAnesthesiologist
Ali Shah Abbasi M.DAli Shah Abbasi M.D..AnesthesiologistAnesthesiologist
CPR consists of:CPR consists of:
1. Airway Management
2. Basic Life Support (BLS)
3. Advanced Cardiac Life Support (ACLS)
4. Advanced Trauma Life Support (ATLS)
5. CPR in special situations
6. Ethical Issues
HistoryHistory
1966 :
National research council conference (generated standards).
2005 :
American Heart Association (AHA).
IntroductionIntroduction
CPR:
Systematic efforts for relief patient from situation which threatened the life.
Effective CPR:
Artificial delivery of oxygenated blood to systemic circulatory beds at rates sufficient for preserving vital organ function and physiologic substrates.
SurvivalSurvival
Highest survival rates and quality of survival are attained when:
- BLS is initiated within 4 min
- ACLS is initiated within 8 min
Management of CPRManagement of CPR
It is a team effort.Coordination of the team is the responsibility of the team leader (Ideally Anesthesiologist).Responsibilities of the team leader:
1- Ensure the quality of BLS.2- Facilitate early use of electrical defibrillation.3- Direct and monitor the adequacy of drug
therapy.4- Ultimately, the team leader decide when
CPR should cease.
IndicationsIndications
1. Unconscious (unresponsive)
2. Abnormal breathing, although there may be brief irregular, gasping breaths
3. Pulselessness or non effective circulation
4. Traumatic patient (electrical, drawing, crash, car accident, …)
To handle a CPRTo handle a CPR
1. Avoid agitation
2. Have a good knowledge
3. Have a good physical ability
What to What to do First?do First?
New DevelopmentsNew Developments
Elimination of lay rescuer assessment of signs of circulation before beginning chest compressions. Simplification of instructions for rescue
breaths should be given over 1second with sufficient volume to achieve visible chest rise. Elimination of lay rescuer training in rescue
breathing without chest compressions.
New DevelopmentsNew Developments……
Recommendation of a (universal) compression-to- ventilation ratio of 30:2 for single rescuers of victims of all ages (except newborn infants).
Increased emphasis on the importance of chest compressions: rescuers will be taught to “push hard, push fast” (at a rate of 100 compressions per minute), allow complete chest recoil, and minimize interruptions in chest compressions.
New DevelopmentsNew Developments……
Recommendation for provision of about 5 cycles (or about 2 minutes) of CPR between rhythm checks during treatment of pulseless arrest. Rescuers should not check the rhythm or a pulse immediately after shock delivery—they should immediately resume CPR, beginning with chest compressions, and should check the rhythm after 5 cycles (or about 2 minutes) of CPR.
New DevelopmentsNew Developments……Recommendation that all rescue efforts, including insertion of an advanced airway (eg, endotracheal tube, esophagealtracheal combitube [Combitube], or laryngeal mask airway [LMA]), administration of medications, and reassessment of the patient be performed in a way that minimizes interruption of chest compressions.
Recommendation of only 1 shock followed immediately by CPR (beginning with chest compressions) instead of 3 stacked shocks for treatment of ventricular fibrillation/ pulseless ventricular tachycardia.
Thanks Thanks For Your For Your AttentioAttentio
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Airway Airway ManagementManagement
Directed ByDirected By::
Behdad Bazargani M.DBehdad Bazargani M.D..AnesthesiologistAnesthesiologist
Ali Shah Abbasi M.DAli Shah Abbasi M.D..AnesthesiologistAnesthesiologist
Conditions need Airway management
General anesthesia
Respiratory failure
Airway obstruction
CPR
Airway AnatomyAirway Anatomy
Nose
Pharynx
Larynx
Trachea
1.Nasopharynx
2.Oropharynx
Airway AnatomyAirway Anatomy
Airway AnatomyAirway Anatomy
Emergency Airway Management Evaluation
Level of consciousness-Alert-Responds to verbal stimuli-Responds to painfull stimuli-Unresponsive
Airway-Patent-Clear
Trauma to cervical spine
Techniques of Airway Management
Non-invasive-Head positioning-Removal of foreign body-Suctioning-Mask ventilation
Invasive-ETT-LMA-Combitube
Airway obstruction
Head tilt chin lift & Head tilt jaw trust
Mask ventilation
One hand mask holding
Two hand mask holding
Oral AirwaysOral Airways
Disposable Berman Airways
Hudson Cath-Guide Airways
Rusch Berman Airways
Rusch Color Coded Guedel Airways
Oral AirwayOral Airway
Nasopharyngeal Airway
Rusch Latex Free Nasopharyngeal Airway
Nasopharyngeal Airway
Endotracheal Endotracheal IntubationIntubation
Indications for Indications for endotracheal intubationendotracheal intubation
1. Provides relative protection against pulmonary aspiration.
2. Maintains a patent conduit for respiratory gas exchange.
3. Provides a means for coupling the lungs to mechanical ventilators.
4. Establishes a route for clearance of secretions.
5. Provides a route for drug administration.
Equipments
LaryngoscopeTubesOxygen sourceBag & MaskSuction
Lubricant
Forceps (Magill)
Adhesive tape
Stylet
Syringe
Stainless Laryngoscope Blades
Laryngoscope Blades
Tracheal Tube
Airway AnatomyAirway Anatomy
Uncuffed Tracheal Tube
Endotrol Tracheal Tube with Controllable Tip
EMT Emergency Medicine Cuffed Tube with Injection Port
ETT sizesETT sizes
Male: No. 8 + 0.5
Female: No. 7 + 0.5
Children: No = + 4 (or 3, for cuffed)Age 4
ETT : sizes (pediartics)ETT : sizes (pediartics)
ETT Depth of insertionETT Depth of insertion
Depth(cm) = + 12
Male: 23 cm
Female: 21 cm
Age
2
ETT : Depth of insertionETT : Depth of insertion
Sniffing Position
35o
80o
Incorrect position
Incorrect position
Sniffing Position
Incorrect positionIncorrect position
Incorrect positionIncorrect position……
laryngoscopy
laryngoscopy
laryngoscopy
Sniffing Position
Laryngeal Mask Airway
Laryngeal Mask AirwayLaryngeal Mask Airway
Laryngeal Mask AirwayLaryngeal Mask Airway
Laryngeal Mask AirwayLaryngeal Mask Airway
LMA-Fastrach
LMA- Fastrach
LMA- Fastrach
LMA-Fastrach
Examples of clinical airway problems managed with the LMA
AcromegalyAnkilosing spondilitisRheumatoid arthritisFacial burnsFailed airway in obstetric patientsFailed rigid broncoscopyFractured jawTemporomandibular joint diseaseLimited mouth openingMicrognathiaNeck contractureFix immobile cervical spineOssification of posterior longitudinal ligamentCervical spinal tumorTreacher CollinsPierre RobinUnstable neck
Characteristics of the LMACharacteristics of the LMA
Sizes Weight (Kg) Cuff Vol.(ml)
#1 <5 4
#1.5 5-10 7
#2 10-20 10
#2.5 20-30 14
#3 30< 20
#4 normal 30
#5 large 40
THE LMA IS NOT DISPOSABLE
Advantages of Using the LMAAdvantages of Using the LMA
leaves provider’s hands freepatient can produce effective coughallows spontaneous ventilationeven malpositioned can adequately ventilate
Disadvantages of LMA over the ETT
Lower seal pressureHigher frequency of gastric insufflationIncreased Aspiration risk
LMA ComplicationsLMA Complications
Aspiration
Coughing
Sore Throat
Combitube
CombitubeCombitube……
Retrograde intubationRetrograde intubation
Retrograde Intubation…
Retrograde Intubation…
Retrograde Intubation…
Retrograde Intubation…
Retrograde Intubation…
CricothyrotomyCricothyrotomy
Cricothyrotomy Devices
CricothyrotomyCricothyrotomy
Cricothyrotomy…
Placement of Needle
Cricothyrotomy…
Wire Guide and Catheter In Place
Cricothyrotomy…
Catheter, Dilator and Wire Guide In Place
Cricothyrotomy…
Rusch QuickTrachRusch QuickTrach
Jet Ventilation
Jet ventilation CatheterJet ventilation Catheter
Thank youThank you
Awake IntubationAwake Intubation
Directed ByDirected By::
Behdad Bazargani Behdad Bazargani M.DM.D..
AnesthesiologistAnesthesiologist
Ali Shah Abbasi M.DAli Shah Abbasi M.D..AnesthesiologistAnesthesiologist
IndicationsIndications
1. Respiratory failure
2. Decrease LOC
3. Difficult airway
Respiratory failure…
Status Asthmaticus
Status Epilepticus
Pulmonary Edema
Chest wall injuries
Etc
GCS
Motor:Category scoreObeys 6
Localizes 5
Withdraws 4
Flexion 3
Extension 2
None 1
GCSGCS
Verbal response:Category scoreOriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
GCSGCS
Eye opening:Category scoreSpontaneously 4
To speech 3
To pain 2
None 1
GCS GCS ==oror<< 8 8
IntubationIntubation
EquipmentsEquipments
Drugs
Ventilator
Laryngoscope
Tubes
Oxygen source
Bag & Mask
Suction
Lubricant
Forceps (Magill)
Adhesive tape
Stylette
Syringe
DrugsDrugs
A- Neuromuscular blocking drugs (NMBDs):
1- Depolarizing NMBDs-
Succinylcholine (1 – 1.5 mg/Kg IV)
2- Non Depolarizing NMBDs-
Vecuronium (0.25 mg/Kg IV)
Cis-atracurium (0.2 mg/Kg IV)
All patients requiring airway management are probably at risk for aspiration of gastric contents (Sellick maneuver).
DrugsDrugs……
B- Sedative-hypnotics: Sodium Thiopental PropofolC- Benzodiazepines: Midazolam (0.5 – 1 mg IV) Diazepam (2 mg IV)D- Opioids: Morphine, Fentanyl, Remifentanil
DrugsDrugs……
E- Beta-adrenergic blocking drugs:
Esmolol (10 – 20 mg IV)
F- Local anesthetics agents:
Lidocaine ( 1 – 1.5 mg/Kg IV or aerosol anesthetic sprays)
G- Nerve blocks…
IV Drugs for Endotracheal IntubationCONDITIONHYPNOSISMUSCLE
RELAXAN
ANALGESIAAMNESIA
GCS=3NoneNoneNoneNone
Cardiacarrest
NoneNoneNoneNone
ShockSBP<80mmHg
NoneSCh1.5mg/kg
Fentanyl0.5-1μg/kg
None
HypotensionSBP
80-100mmHg
Thiopental0.3-1mg/kg
SCh1.5mg/kg
Fentanyl1-2μg/kg
Midazolam1-2mg
Head injuryGCS 4-9
Thiopental2-5mg/kg
SCh1.5mg/kg
Fentanyl1-2μg/kg
Midazolam1-2mg
CombativeNormal BP
Thiopental2-5mg/kg
SCh1.5mg/kg
Fentanyl1-2μg/kg
Midazolam1-2mg
Sellick’s maneuverSellick’s maneuver
ThenThen……
Ask for Ask for VentilatorVentilator
Thank YouThank You