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

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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

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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

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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

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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

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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?

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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

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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

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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

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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

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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

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