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Airway Management Milwaukee Challenges in Airway Patency

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Airway Management Milwaukee Challenges in Airway Patency 8/22/2014 Airway Management Does this patient need an emergent airway? Milwaukee Challenges in airway patency Tongue Blood Dental Trauma Vomit Distorted Landmarks Reflex Jaw Spasm C-Spine Injury 1 8/22/2014 Immediate Assessment Parameters Adequacy of current ventilation Patency of airway Duration of hypoventilation Need for paralyzing agents C-Spine injury Equipment and Experience Airway Stabilization Techniques Positioning to relieve tongue obstruction Chin Lift or Jaw Thrust (No Neck lift, or extension!!) Elevated head position EAC to sternal notch Elevate with sheets or blanket Nasopharyngeal Airway Prevent tongue from obstructing airway Frees the operator to do other things Insertion technique simple 2 8/22/2014 Nasal Intubation? LaFort III Fracture I wouldn’t Suboptimal intubation Oropharyngeal Airway Prevents tongue from obstructing airway Insert inverted along hard palate then twist Size by corner of mouth to EAC 3 8/22/2014 Bag-Valve-Mask May be the most important airway skill Tight Mask seal is mandatory Two man technique best Incidence of impossible BVM? Cyclists are ideal patients!! Gastric distention… overly concerned Oxygenation Technique Slow 1-2 second breaths TV goal 450cc, every 5 seconds, 12BPM Cricoid pressure? Role for paralytics? Oxygen flow NODESAT technique NC @15LPM Place a nasal cannula too? Definitive Airway Indications Coma and lack of gag reflex (GCS<8) Severe facial trauma Aspiration Risk Expanding neck hematoma, edema or stridor Impending respiratory failure Hypoxia or inability to adequately ventilate with noninvasive methods 4 8/22/2014 Bridge Airways EOA, King Airway, Combitube, LMA Next step in airway management More invasive Temporary Buys time to Endotracheal intubation Best to use Laryngoscope to assist placement (except LMA) EOA (Esophageal Obturator Airway) King Airway 5 8/22/2014 Combitube difference LMA Endotracheal Intubation Gold Standard Does this need to be done now? Would this be more easily done in the ED? How adequate is the current airway situation? How long is my transport? 6 8/22/2014 Basic Intubation Equipment ETT best #8 taped around 22cm depth, 5-8cc in cuff Laryngoscope and blades (Mac/Miller) usually 3-4 Getting a view and around the tongue Sweep the whole tongue left up and out of the way to visualize the cords holding the laryngoscope with left hand Anatomy View for ETT placement Keep inserting until tip placed in vallecula (MAC blade) Pull up hard but don’t rock Deliver tube from below Bimanual Laryngoscopy 7 8/22/2014 Proof of Placement Watch tube go into the trachea ETCO2 Pulse Ox Chest rise and bilateral breath sounds No breath sounds over epigastrium ETCO2 Detector Turns yellow when detects CO2 (good intubation) probably… Look for tube though the cords, bilateral BS, fogging tube Keys to first pass intubation Preparation Preoxygenation NODESAT Pretreatment Paralysis Placement Proof Post Intubation management 8 8/22/2014 Mexico 2008 I didn’t get the tube… now what? Bag and try again if SaO2 OK Go back to BVM Consider adjuncts (Bougie)/Toys Consider bridge airways If all else fails surgical airway a consideration Airwaycam.com AirTraq Glidescope 9 8/22/2014 What we have in the ED Fiberoptic Scope Airway Cart Glidescope Lighted stylet Bougies Flipper Cric kit Retrograde kit Quick trach Better suction I don’t think you have this on your back What we have in the ED Lots of Stuff It’s easier in the ED! Three day course only for emergency airway Also Suggest Airwaycam website and courses airwaycam.com 10 8/22/2014 My own misadventures Last time I road fixed gear Ideas for next year Race Bag content and survey (include dressing bag) Meds that are good to have QR powder More time with the airway station Less time with the Chest tube Head injury assessment scenario Quick ER tricks that are useful Ortho reductions 11.
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