Difficult Airway Toolkit 10.22.23 PM

Difficult Airway Toolkit 10.22.23 PM - Some Tools for Some...

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Unformatted text preview: Some Tools for Some Managing the Difficult Airway Airway Joe Lex, MD, FAAEM Temple University Philadelphia, PA Emergency Medicine Emergency Medicine Airway management is really easy… Airway …except when it isn’t… except Our Options Are Different • Anesthesiology Plan in advance Can’t get airway... …awaken patient …regroup …go for coffee Emergency • What will be, will What be be Can’t get airway… …wipe brow …change shorts …call attorney …call coroner Emergency Medicine Emergency Medicine It can be difficult to… …oxygenate …ventilate …intubate …perform cricothyrotomy Emergency Medicine Emergency Medicine To Maximize Success… …recognize and predict difficult recognize airway airway …choose appropriate technique choose and equipment and …possess technical skills, drugs, possess and devices and Emergency Medicine Emergency Medicine Predicting the Predicting Difficult Airway Difficult …if you have time Emergency Medicine Emergency Medicine LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility Emergency Medicine Emergency Medicine Look at Anatomy • • • • Obesity: rapid desaturation, difficult rapid intubation, ventilation intubation, Facial hair: hides small chin, can hides make bagging difficult / impossible make Large teeth: hide airway, obscure hide tube passage tube Jagged teeth: lacerate balloon Emergency Medicine Emergency Medicine Look at Anatomy Emergency Medicine Emergency Medicine Look at Anatomy • • • Narrow face, high-arched palate: decreased side-to-side diameter decreased Large tongue: hides airway False teeth: help bagging, remove help for intubation for Emergency Medicine Emergency Medicine Examine Airway Emergency Medicine Emergency Medicine Examine Airway • • • The 3 – 3 – 2 rule Mouth open: 3 fingers Mentum to hyoid: 3 fingers Floor of mouth to thyroid Floor cartilage: 2 fingers cartilage: Emergency Medicine Emergency Medicine Examine Airway • Mouth open: 3 fingers Allows insertion of tube, Allows laryngoscope laryngoscope • Mentum to hyoid: 3 fingers Predicts ability to lift tongue Predicts into mandible into Emergency Medicine Emergency Medicine Examine Airway • Floor of mouth to thyroid Floor cartilage: 2 fingers cartilage IIf high larynx, airway tucked f under base of tongue, hard to visualize visualize Emergency Medicine Emergency Medicine Mallampati Score • • With patient seated: extend With neck open mouth stick out tongue out Visualize base of tongue, Visualize faucial pillars, uvula, pharynx faucial Emergency Medicine Emergency Medicine Mallampati Score Mallampati Difficulty None None Moderate Severe Airway Obstructions Airway Obstructions Emergency Medicine Emergency Medicine Airway Obstructions Airway Obstructions • • Angioedema? Hematoma? Look under shirt collar • • Dentures? Epiglottis? Emergency Medicine Emergency Medicine Neck Mobility Prior condition • Surgery • Rheumatoid Rheumatoid arthritis arthritis • Osteoarthritis • Others Emergency Medicine Emergency Medicine Neck Mobility Emergency Medicine Emergency Medicine Neck Mobility • • Cervical spine rigidity: Cervical reduces ability to align anatomic axes anatomic Inability to mobilize neck can Inability make intubation difficult or impossible impossible Emergency Medicine Emergency Medicine Moving Beyond Laryngoscopy Moving Some Equipment, Old & New Some Difficult Airway Cart • • • • • Bag valve mask Combitube™ LMA Intubation LMA Fiberoptic: rigid, Fiberoptic: flexible flexible • • • • • • Lightwand Bougie Transtracheal jet Retrograde Digital Digital Cricothyrotomy Emergency Medicine Emergency Medicine 1. Bag Valve Mask 1. 1. Bag Valve Mask (BVM) • • • • Practice: skills essential Use appropriate size oral airway or Use nasal trumpet nasal Leave dentures Use water-soluble lubricant to get Use good seal, especially if lots of facial hair hair Emergency Medicine Emergency Medicine 2. Combitube® 2. 2. Combitube® • • • • Double lumen tube functions as Double esophageal obturator airway plus standard cuffed endotracheal tube standard Insert blindly 90% esophageal Insert Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL Emergency Medicine Emergency Medicine 2. Combitube® • • Seals oropharyngeal and Seals nasopharyngeal cavities nasopharyngeal Ventilate through blue port Good breath sounds and no air in Good stomach continue ventilating No breath sounds and air in stomach No use white tube Emergency Medicine Emergency Medicine 2. Combitube® Emergency Medicine Emergency Medicine 3. Laryngeal Mask Airway 3. Indications • • • Routine / emergency procedures Routine Known / unknown difficult airway Known During resuscitation in profoundly During unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible not Emergency Medicine Emergency Medicine Contraindications In elective patient who… In elective …has not fasted …may have gastric contents …has fixed lung compliance has …is not profoundly unconscious …resists LMA airway insertion Emergency Medicine Emergency Medicine Usage Emergency Medicine Emergency Medicine Usage Emergency Medicine Emergency Medicine Usage Emergency Medicine Emergency Medicine Usage Emergency Medicine Emergency Medicine Usage Emergency Medicine Emergency Medicine 4. Intubating LMA 4. Emergency Medicine Emergency Medicine LMA Take-Home Points • • • • • Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient Keep awake awake Don’t throw out!! Used 40 – 50 Don’t times times Emergency Medicine Emergency Medicine 5. Flexible Fiberoptic Scope 5. 5. Flexible Fiberoptic Scope Advantages • • • • • Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement Emergency Medicine Emergency Medicine 5. Flexible Fiberoptic Scope Disadvantages • • • • Expensive Expertise requires practice Expertise Delicate equipment needs careful Delicate maintenance maintenance Visual field easily impaired by blood Visual and secretions and Emergency Medicine Emergency Medicine 6. Rigid Fiberoptic Scope 6. 6. Rigid Fiberoptic Scope Bullard Bullard Wu Scope Wu Emergency Medicine Emergency Medicine 6. Rigid Fiberoptic Scope Upsher Upsher GlideScope GlideScope Emergency Medicine Emergency Medicine 6. Rigid Fiberoptic Scope Levitan Scope Emergency Medicine Emergency Medicine 6. Rigid Fiberoptic Scope Advantages • • • • • Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments Durable, Emergency Medicine Emergency Medicine 6. Rigid Fiberoptic Scope Disadvantages • • • • Expensive Expertise requires practice Visual field easily impaired by blood Visual and secretions and Not readily available Emergency Medicine Emergency Medicine 7. Lightwand (Trachlight) 7. 7. Lightwand (Trachlight) 7. 7. Lightwand (Trachlight) Advantages • • • • • Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway Emergency Medicine Emergency Medicine 7. Lightwand (Trachlight) Disadvantages • • • • Blind technique May damage airway Usually requires darkened room Expertise requires practice Emergency Medicine Emergency Medicine 8. Intubating Stylet (Bougie) 8. 8. Intubating Stylet (Bougie) • Gum elastic – use as guidewire Advantages • • • • Gives definitive airway Easy to learn Inexpensive Can be used blindly Emergency Medicine Emergency Medicine 8. Intubating Stylet (Bougie) • Gum elastic – use as guidewire Disadvantages • • Expertise requires practice Not recommended in “can’t intubate Not / can’t ventilate” scenario can’t Emergency Medicine Emergency Medicine 9. Transtracheal Jet Ventilation 9. 9. Transtracheal Jet Ventilation Advantages • Surgical airway of choice if 8 years Surgical or younger or • Effective • Can serve as temporary airway Can before permanent airway • Relatively simple procedure Emergency Medicine Emergency Medicine 9. Transtracheal Jet Ventilation Disadvantages • Significant complications if Significant misplaced misplaced • Need proper equipment • Need high-pressure oxygen • Does not protect against aspiration Emergency Medicine Emergency Medicine 10. Retrograde Intubation 10. 10. Retrograde Intubation • • • • Puncture cricothyroid membrane Thread wire through vocal cords Exit nose or mouth Guide endotracheal tube through Guide vocal cords over wire vocal Emergency Medicine Emergency Medicine 10. Retrograde Intubation Advantages • • • Definitive airway Minimal neck movement Does not require full mouth open Emergency Medicine Emergency Medicine 10. Retrograde Intubation Disadvantages • • • Takes time Requires skill Not recommended in cannot Not intubate / cannot ventilate intubate Emergency Medicine Emergency Medicine 11. Digital Intubation 11. 11. Digital Intubation • • • You need long fingers Make sure patient is really Make unconscious unconscious Not commonly used, but can be lifesaver Emergency Medicine Emergency Medicine 11. Digital Intubation Indications • • • • Poor lighting, difficult patient Poor position, disrupted airway, potential cervical spine injury cervical Can’t see larynx due to blood Equipment failure Intubation failure Emergency Medicine Emergency Medicine 12. Cricothyrotomy 12. 12. Cricothyrotomy • • • Life-saving technique Surgical vs. needle / Seldinger vs. Surgical percutaneous kit percutaneous You must know this procedure You before starting rapid sequence before Emergency Medicine Emergency Medicine 12. Cricothyrotomy • • Final common pathways for all Final cannot intubate / cannot ventilate scenarios scenarios “The hardest part of doing a The cricothyrotomy is picking up the knife.” – Peter Rosen knife.” Emergency Medicine Emergency Medicine And finally… BURP your patient – grab the larynx BURP and give… and …Backward …Upward …Rightward …Pressure Emergency Medicine Emergency Medicine Conclusions • Recognize the difficult airway • • How much time do you have? Who else is around? What is your backup procedure Know both old and new methods Choose backups based on skills Emergency Medicine Emergency Medicine Dziękuję bardzo [email protected] [email protected] [email protected] Emergency Medicine Emergency Medicine ...
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This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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