Thank you

EXTREME Airways Crisis Performance..Rethinking our Approaches

finding landmarks

hypoxia

cric

Richard Levitan @airwaycam airwaycam@gmail.com

Stress & Fear

fluids

Call for help!

Call for help!

ENGINE FAILURE DURING FLIGHT1.FAILED ENGINE CONDITION LEVER - FEATHER & FUEL SHUT-OFF.2.Operative engine power lever - ADVANCE, as required.3.Gear - UP.4.Flaps - UP.5.Maintain minimum single-englne speed or above.6.Stores - JETTISON, as required.7.Attempt air starts.8.Failed engine power lever - FLIGHT IDLE.9.Failed engine FUEL EMERG SHUT OFF - SHUT OFF.

FAILURE OF BOTH ENGINES IN FLIGHT1.Maintain 130 KIAS.2.Fuel quantity - CHECK.3.Attempt air starts.

ELECTRICAL FIRE1. Generators - OFF.2. BATTERY - OFF.3. RAM AIR knob - PULL FULL OUT.4. All electrical equipment - OFF.5. BATTERY - ON.6. Generators - RESET separately.7. Voltammeter - CHECK during generator

reset.8. Defective equipment - ISOLATE.

incremental steps… 1st steps very important

To do two things at once is to do neither. —Publilius Syrus

one step at a time…

overcoming extremes

WHEN THERE IS A PERCEIVED IMBALANCE BETWEEN THE DEMANDS OF THE EMERGENCY AND YOUR PERCEPTION OF YOUR ABILITY TO MEET THOSE DEMANDS.

STRESS: Increased heart rate > compromises fine motor skills > affects breathing, vision, and fatigue

STRESS: impedes judgement, impairs focus, goofy loop—stuck on stupid.

PERFORMANCE STRESS

PERCEPTION

PERCEPTION

PERCEPTION

PERCEPTION

Intubation: Do you see the cords?

Hypoxia: Can you bag the patient?

Cric: Can you feel the CTM?

WRONG QUESTIONS! we’re rushing….slow is smooth, smooth is fast

Intubation: Do you see the cords?

Accept reality and responsibilityControl your thoughts: Self-talkControl physical response to stress: Breathing and muscle relaxation techniques, stabilization of hands, biomechanics.

Process insight: One step at a time

Procedural insights:Pre-oxygenation & apneic

oxygenationPositioning to optimize oxygenationPositioning to reduce regurgitationEar-to-sternal notch positioningMechanics of the upper airwayEpiglottoscopy Progressive landmark exposureBimanual laryngoscopyOpto-mechanics of tube delivery

Oxygenation is PRIORITY—not plastic

Vomit—active/passive—is THE enemyof direct/video laryngoscopy, mask,LMA/King, passive oxygenation &fiberoptics—every part of the process

- 2 finger grip at base of handle- Scissor opening mouth- Roll blade down tongue- Visualize uvula- Yankauer suction hypopharnyx- Lift tongue and jaw- Visualize epiglottis- Check tongue position- Blade right, tongue left

- Full grip on handle, thumb up- Blade aligned with forearm- Advance tip into vallecula- Bimanual laryngoscopy- Move larynx side to side- Move larynx posteriorly- Repeat suctioning as needed- Use assistant’s hand as needed- Head elevation as needed

- Bougie or straight-to-cuff stylet- Insert into right corner of mouth- Place behind maxilla, move to larynx- Pivot tube or bougie corner mouth- Advance tip over notch- Tracheal ring impaction > Rt turn- 21-23cm at teeth male/female- Inflate cuff, end-tidal CO2, pulse ox

Epiglottoscopy LaryngoscopyTube delivery

Introduction & Epiglottoscopy and Controlling Tongue

First Stage: 2 Fingers

Keys to Epiglottoscopy

★ – Proceed slowly, methodically midline down tongue ★ – Distract tongue and jaw forward, and lift epiglottis edge off the posterior

pharynx ★ – A light grip allows fine adjustment and fine tongue control

Beware of epiglottis camouflage !

fluids, blood, saliva pool in hypopharynx –

use suction tip if needed to clear hypopharynx and see

epiglottis edge

epiglottis: - reliable anterior landmark - able to be lifted out of fluids - top of laryngeal inlet

Epiglottoscopy

Epiglottoscopy: The Secret to the Airway Any Device—One Approach…find the epiglottis on insertion

Storz DCI Video Laryngoscope

Compartmentalize and then flatten the slope: Reduce each section of the procedure to its basic components

Individual steps are small, reliable, achievable, & reproducible.

Lighten the load (Mindset): Keep the wheelbarrow light and balanced

Engineering Procedural Teaching & Training for Crisis Performance

Tube delivery

Laryngoscopy

Epiglottoscopy2 finger grip roll midline down tongue

dab uvula, palatal arch, epiglottis

tongue controlbimanual

head lift

shape, bevel, rings

ear - sternal notch face plane parallel to ceiling

Hypoxia: Can you bag the patient?

36% of unconscious, non-paralyzed patients have complete UAO and 54% had partial UAO when the head was in the neutral position (Safar)

Lesson from Bromiley case: Failure to cut or…

wrong approach to oxygenation?

The NOSE is BETTER !

• No cheek flap • No pressure on unstable

joint (jaw) • Nasal has better

ventilation volumes vs oral/nask mask

• Soft palate functions as emergency exit door

Anesthesiology, V 108, No 6, Jun 2008 Liang et. al

NASAL MASK

ORAL- NASAL MASK

Can 15 lpm unobstruct airway?

Soft palate

Epiglottis

Tongue

Base

upright–good for alveoli, diaphragm, fluids passive patent airway is via the nose

pull mandible to unobstruct base of tongue, epiglottis

O’s Up the Nose Pull mandible forward

Sit patient up Oxygen On Pull mandible Sit patient up

OOPS

Cords

If you must ventilate… 1) Upright 2) Continuous flow O2 NC 3) PEEP valve

Maximizes FiO2 and alveolar-capillary absorption

Cric: Can you feel the CTM?

Mental Armor Will I cause

harm?

Do I have the skill set?

Am I sure where to cut?

Is it really needed?

The Surgically Inevitable Airway The Cartilaginous Cage

The Laryngeal Handshake Sternal Stabilization

Save a Life… Cut the neck.

back wall of the cricoid

cartilage

a firm stop... so don’t be

fearful !

Cricoid ring front: 2.5-5.0 mm Back wall:

16 - 29 mm

a firm stop... so don’t be

fearful !

Cricoid ring front:

2.5-5.0 mm

Cricoid back wall:

16 - 29 mm

2.5-5.0 mm

16-29 mm

“The Laryngeal Handshake” …rock the rhomboid

5 fingers >>>> not 1 finger Find midline >>>> not the CTM >>> vertical cut, then verify location CTM

Epiglottis = the center of the world in the internal airway Thyroid = center of the world for external laryngeal landmarks

Save a life & cut the neck! Rock the Rhomboid! Rock the Rhomboid!

Save a life & cut the neck! Rock the Rhomboid!

1. Laryngeal handshake 2) Non-dominant stabilizes larynx

3) vertical incision 4) verify CTM with finger 4) Sternal stabilization

Incrementalize Your Procedures

Performance Stress Beauty / Death Ratio

Celebrate the Victories

Richard Levitan @airwaycam airwaycam@gmail.com