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Basic Emergency Airway Management Pat Melanson,MD

Basic Emergency Airway Management Pat Melanson,MD. Objectives. Differentiate the Emergency Airway from elective intubation in the OR Assessment of airway compromise Indications for airway intervention Recognition of the difficult airway Bag-Mask Techniques Laryngoscopy.

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Basic Emergency Airway Management Pat Melanson,MD

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  1. Basic Emergency Airway ManagementPat Melanson,MD

  2. Objectives • Differentiate the Emergency Airway from elective intubation in the OR • Assessment of airway compromise • Indications for airway intervention • Recognition of the difficult airway • Bag-Mask Techniques • Laryngoscopy

  3. Emergency Airway Management : Unique Considerations • Full stomach - high aspiration risk • Altered level of consciousness • Deteriorating cardiorespiratory physiology - (hypotension, hypoxia) • Abnormal or distorted upper airway anatomy • No time for “pre-op” assessment

  4. Airway Assessment • Assessment for airway compromise or threats and need for interventions • Examination for the potentially difficult airway

  5. The Three Pillars of Airway Management: ( Assessment of Compromises or Threats ) • Patency of Upper Airway • ( airflow integrity ) • Protection against aspiration • Assurance of oxygenation and ventilation

  6. Indications for Active Airway Intervention: including intubation • Failure to maintain patency • Protection from aspiration • Hypoxic/ hypercapnic respiratory failure • Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation • Intractable Shock • Anticipated clinical deterioration

  7. Indications for Intubation • Is there failure of airway maintenance ? • Is there failure of airway protection ? • Is there failure of oxygenation or ventilation? • What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

  8. Clinical Signs of Airway Compromise : Threatened Patency • Inspiratory stridor • Snoring ( pharyngeal obstruction ) • Gurgling ( blood/ secretions ) • Drooling ( epiglottitis ) • Hoarseness ( laryngeal edema/ vocal cord paralysis) • Paradoxical chest wall movement • Tracheal tug • Mass - abscess, hematoma, angioedema

  9. Clinical Signs of Airway Compromise: Inadequate Protection • Blood in upper airway • Pus in upper airway • Persistent vomiting • Loss of protective airway reflexes • swallowing reflex is superior to gag reflex

  10. Clinical Signs of Airway Compromise:Oxygenation and Ventilation • Central cyanosis • Obtundation and diaphoresis • Rapid shallow respirations • Accessory muscle use • Retractions • Abdominal paradox

  11. Clinical Signs of Airway Compromise:Oxygenation and Ventilation • The assessment of oxygenation and ventilation is a clinical one. • Arterial blood gases should not be relied upon to assess whether intubation is necessary.

  12. Techniques for the Compromised Airway • Head Positioning • Jaw Thrust, Chin lift • Orophryngeal/ Nasopharyngeal airways • Bag-Valve-Mask Ventilation • Endotracheal Intubation • Advanced techniques • Cric, LMA, Combitube, Retrograde, Fibreoptic, Light wand, Bouge

  13. The Difficult Airway • Difficult Laryngoscopy • poor visualization of cords • Difficult bag-mask ventilation • unable to oxygenate or ventilate • Lower airway difficulty • severe bronchospasm

  14. Golden Rules of Bagging • “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “ • The art of bagging should be mastered before the art of intubation • Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

  15. BVM Ventilation • The most important airway skill • Always the first response to inadequate oxygenation and ventilation • The first “bail-out” maneuver to a failed intubation attempt • Attenuates the urgency to intubate • Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

  16. BVM Ventilation • Requires practice to master • One hand to • maintain face seal • position head • maintain patency • Other hand ventilates

  17. BVM Ventilation: Technique • Insert oropharyngeal/nasopharyngeal • “Sniffing”position if C-spine OK • Thumb + index to maintain face seal • Middle finger under mandibular symphysis • Ring/little finger under angle of mandible • Maintain jaw thrust/mouth open

  18. Predictors of a Difficult Airway : BVM • Upper airway obstruction • Lack of dentures • Beard • Midfacial smash • Facial burns, dressings, scarring • Poor lung mechanics • resistance or compliance

  19. Difficult Airway : BVM • degree of difficulty from zero to infinite • Zero = no external effort or internal device required • one person jaw thrust/ face seal • oropharyngeal or nasopharyngeal AW • two person jaw thrust / face seal • both internal airway devices • Infinite = no patency despite maximal external effort and full use of OP/NP

  20. Algorithm for Difficulty “Bagging” • Remove Foreign Bodies - Magill forceps • Triple maneuver if c-spine clear • Head tilt, jaw lift, mouth opening • Nasal or oropharyngeal airways • Two-person, four-hand technique

  21. BVM Ventilation: Mask Seal Tips and Pearls • Easier to get seals with masks too large than too small • Inflate mask collar correctly • Apply lubricant to beards to “mat down” hair • If edentulous insert gauze sponges into cheeks

  22. Prediction of the Difficult Airway: Laryngoscopy • History of past airway problems • check previous OR anesthesia records if time permits • cricothyroidotomy scar • Careful physical assessment • mouth opening • tongue to pharyngeal size • hyo-mental distance • Neck flexion, Head extension

  23. Technique of Laryngoscopy • “Sniffing” position to align oral-pharyngeal-laryngeal axis • Flex neck by placing pillow beneath occiput ( raise 10 cm ) • Extend head maximally • With laryngoscope • open mouth fully • push tongue to left out of view • pull upward at 45 degrees

  24. Adducted vocal cords

  25. Predictors of Difficult Laryngoscopy • Short thick neck • Receding mandible • Buck teeth • Poor mandibular mobility/ limited jaw opening • Limited head and neck movement • ( including trauma )

  26. Difficult Airway : Laryngoscopy • Tumor, abscess or hematoma • Burns • Angioneurotic edema • Blunt or penetrating trauma • Rheumatoid arthritis, ankylosing spondylitis • Congenital syndromes • Neck surgery or radiation

  27. Predictors of Difficult Laryngoscopy • 3 fingerbreadths mentum to hyoid • 3 fb chin to thyroid notch • 3 fb upper to lower incisors • Head extension and neck flexion • Mallimpadi classification • Previous history of difficult intubation

  28. Mallimpadi Classification (Tongue to Pharyngeal Size) • I - soft palate, uvula, tonsillar pillars visible • 99 % have grade I laryngoscopic view • II - soft palate, uvula visible • III - soft palate, base of uvula • IV - soft palate not visible • 100% grade III or grade IV views

  29. The 4 D’s of Difficult Intubation • Distortion • ( edema, blood, vomitus, tumor, infection) • Dysmobility of joints • ( TMJ, alanto-occipital, C-spine) • Disproportion • thyomental, Mallimpadi, etc • Dentition • prominent upper teeth

  30. Unsuccessful Intubation • Bag the patient • Maximize neck flex/ head ex • Move tongue out of line of site • Maximize mouth opening • ID landmarks and adjust blade • BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.) • Increasing lifting force • Consider Miller blade • Bag the patient

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