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Airway Management

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by

Joe Rauscher

on 31 July 2016

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Transcript of Airway Management

Airway Management
St. George's University Emergency Medicine Club
Basic Airway Maneuvers
Advanced
Airway Maneuvers

Objectives
Indications
Airway Anatomy
Choice of Algorithm
Crash
Difficult
RSI
Failed
Universal Algorithm
“The paramount step fundamental to the safe conduct of airway management is airway evaluation and recognition of potential difficulty”
- S. Rao Mallampati, MD
Recognizing the critical care patient with respiratory compromise
Effectively acting to manage respiratory complications through an algorithmic approach
Use of Basic and Advanced techniques
Altered Level of Consciousness
Respiratory Compromise
Hypoxia, Pneumonia, Pneumothorax, etc...
Toxicological
Accidental vs. Self-induced vs. Medically-induced
Neurological Compromise
CVA, Seizures, etc...
Hemodynamic Compromise
Poor Ejection Fraction, CHF, MI, Cardiac Tamponade, etc...
Sepsis
Renal Disease
Cellular Waste Toxicity, Electrolyte Imbalances, etc...
Combative
Post medically-induced sedation
Cerebrovascular Injury/Lesion
Airway compromise
Burns
Choking
Tongue, Dentures, Food, Emesis, Blood, Etc...
Anaphylaxis
Allergies - Bees, Foods, Medications
Surgical Intervention
Medically-induced coma vs. facilitated awake intubation
Anticipated Clinical Course
Assessment
Airway

General Appearance
Is it Open/Clear?
Patency without Adjuncts?
Dental Devices?
Position of Patient
Anatomical Defect
Acquired vs. Congenital
Oral/Nasal Disease?
Breath Odor?
Breathing

Rate, Rhythm, Depth, Pattern
Visulaization of Chest Wall
Auscultation of lung sounds
Palpation of chest wall
Assessment of Oxygenation
SpO2, Capnography, ABG
Circulation

Signs of Respiratory Compromise
Heart Rate, Rhythm, Quality
Skin
Color, Temperature, Condition, Capillary Refill Time
History of the Present Illness

Onset/Duration
Signs/Symptoms
Manifestations
Outcomes from home treatments
How much time do you think you have?
Patient needs airway management
Unconscious/Unresponsive
Yes
No
OPA/NPA
Suction
Oxygen
Difficult Airway Assessment
Yes
No
Positioning
BVM
"Can't Intubate, Can't Ventilate"
Can the patient maintain their airway AND can they protect their airway against aspiration?

Can the patient maintain ventilation AND can the patient maintain oxygenation?

Is the patient’s likely clinical course going to require intubation?
Three Main Questions
Head-Tilt Chin-Lift
Jaw Thrust
vs.
Proper Sniffing Position with use of a pillow .... or many pillows
Sizing
Wall Mount
Oxygen Tanks
Oxygen

Delivery

Percentages

Room Air 21%
Nasal Cannula 24-44%
Simple Face Mask 40-60%
Partial Face Mask 40-60%
Venturi Mask 24, 28, 36, 40%
Non-Rebreather 60-(100)%
BiPAP/CPAP 100%
Techniques
One Handed vs. Two Handed
Wall Mounted
Yankauer
Portable Unit
French Tipped
Contraindications for Nasal Insertion:
Head or Facial Trauma
Positioning
Direct Laryngoscopy
Assessments
during and post
successful intubation
Preparation
Plan
PPE
Gloves, Mask, Gown, Eye Protection
BVM, OPA's, NPA's, Suction, Pulse Oximetry
Assistant(s)
Laryngoscope
Multiple Blades
Multiple Sizes and Shapes
Endotracheal Tube (ETT)
Multiple Sizes - (Adult Sizes 6.0-9.0, avg. 7.0)
Syringe (10 mL for ETT)
Stylet + Bougie
ETT Secure Device
Water-Soluble Lubricant
Magill Forceps
Confirmation Devices
EDD, EtCO2 with waveform capnography, Stethoscope

Contingency Plan
Back Up Devices and their appropriate related equipment
Preparation
Preoxygenation (BVM with NC)
Several Minutes for Nitrogen Washout
Position
Placement
Proof
Post-Intubation Management
Cords = ~15 cm
Sternal Notch = ~20 cm
Carina = ~25 cm
Waveform Capnography
Lung Sounds
Direct Visualization
CXR
Difficult Airway/Contingency Plans
Bougie
King LT
Laryngeal Mask Airway
External Laryngeal Movement
Video Laryngoscopy
Failed Airway
"Can't Intubate, Can't Ventilate"
Last and Final Options
Needle Cricothyrotomy
Surgical Cricothyrotomy
St. George's University
Emergency Medicine Club
Airway Management
Joe Rauscher, AAS, BS, NRP, FPC
MD Candidate, St. George's University

jrausch1@sgu.edu
http://www.sguemc.com

secretary@sguemc.com

http://www.facebook.com/groups/sguemc
Live Surgical Cricothyrotomy
on a Patient with Return of Spontaneous Circulation
Post Cardiac Arrest
http://emcrit.org/wee/real-surgical-airway/
Direct Laryngoscopy
Skills and Techniques of Intubation
http://emcrit.org/podcasts/emcrit-intubation-checklist/
Two Videos:
The First is a Video of Direct Laryngoscopy
The Second is a comprehensive overview of preperation
Laryngeal Tubes
Plan
PPE
Gloves, Mask, Gown, Eye Protection
BVM, OPA's, NPA's, Suction, Pulse Oximetry
Assistant(s)
Laryngeal Tube
Appropriate Size
Size 3 - Height: 4-5 ft
Size 4 - Height: 5-6 ft
Size 5 - Height: 6+ ft
Syringe
Size 3 - 50 mL
Size 4 - 70 mL
Size 5 - 80 mL
Secure Device
Water-Soluble Lubricant
Confirmation Devices
EtCO2 with waveform capnography
Stethoscope

Contingency Plan
Back Up Devices and their appropriate related equipment
HPI
: Patient reports to the nurse that he has had chest pain for 2 hours. Initial EKG showed an inferior wall acute myocardial infarction. Labs were drawn and you are called in to see the patient.
HPI
: Your patient has been an inpatient in your hospital for 2 days with worsening shortness of breath. due to a pneumonia. Prescribed antibiotic and respiratory treatments have had minimal effect on his complaints.

Vitals
:
HR: 130 bpm
BP: 90/50
RR: 8

PE
:
General: Lethargic, speaks in 1-2 word sentences
HEENT: Pupils equal and sluggish to light
Chest:
Deep, agonal, bradypneic respirations
, equal chest rise,
Lung sounds have rhonchi diffusely and bilaterally
Abdomen: soft
Extremities: cool, clammy, pale
Advanced Airways for Time Critical Patients
Basic
Advanced
Preparation
Practice
Full transcript