Amy Gutman MD ~ EMS Medical Director [email protected] / www.TEA.EMS.com

•

Identifying the difficult airway

•

Decision-making algorithms

•

Difficult Airway Toolkit

•

Hail Mary Adjuncts

•

Difficulty providing adequate ventilation due to personal, clinical & / or physical characteristics

•

Every airway is difficult until a tracheal tube is confirmed

•

If you’ve never missed an airway, do not assume that you never will

•

The Difficult Airway Algorithm is a step by step approach at evaluating a patient’s ability to maintain an open airway & your ability to manage that airway

•

“Master BVM. There are few airway emergencies in the prehospital setting not managed adequately with proper bag & mask ventilation until the patient can be transported to the hospital”

~Ron Walls MD

•

Maintain airway:

• •

Jaw-thrust, head-tilt, chin-lift OPA, NPA

•

Ventilation Assistance

•

Synchronous & rhythmic

•

Maintain seal & low airway pressures

•

Don’t forget O 2 !

•

Can’t Intubate, Can Ventilate

•

2 unsuccessful advanced airway attempts

•

BVM maintains O 2 > 90%

•

Can’t Intubate, Can’t Ventilate

•

2 unsuccessful advanced airway attempts

•

Cannot maintain O 2 BVM > 90% with

Maintaining & Protecting Airway? Ventilating?

Oxygenating?

No Yes

Reposition, O2 Dextrose Narcan

Successful Unsuccessful

Likely deterioration?

No Yes

Rapid Transport BVM CPAP O2 Transport Advanced Airway BVM Advanced Airway

ETI / NTI Unsuccessful Cricothyrotomy Or Retrograde Alternatives: Biluminal LMA Combitube Lighted Stylette Successful Successful Post Airway Management

•

A: “Alternate”

•

Tube

• •

Blade Approach

•

B: “Blind, BVM, Bougie”

• • •

Blind BVM Bougie-assisted

•

C: “Cric”

•

Surgical Airways

• • • •

L E M O N Look Externally Evaluate 3-3-2 Mallampati Obstruction Neck Mobility

• • • • •

M O A N S Mask Seal Obese Aged > 55yo No Teeth Snores / Stiff

You GUARANTEE Failure If You Do Not Prepare!

• • • • • • • • • • • • •

Preoxygenate, BVM, Full O 2 2 large bore IV / IO & IVF tank Monitor 2 sizes ETT, checked cuffs, back-up Blade, checked light, back-up Alternative airway checked Handle, checked batteries, back-up Stylette, back-up Suction McGills ETCO 2 detector, back-up Syringe x 2 Manpower & tape

• • • • • • • • • •

Endotracheal Digital Bougie Nasotracheal LMA Supraglottic Awake Fiberoptic Videoscope Surgical

Endotracheal Intubation

•

Neutral to head-tilt / chin-lift (no trauma)

•

Scissor open mouth with right hand

•

Remove dentures or foreign bodies

•

Grasp laryngoscope in left hand

•

If using a Miller, pass to right of the tongue, advance into hypopharynx, pushing tongue to the left

•

Lift laryngoscope up & forward to expose vocal cords

•

If using a Macintosh: advance blade into hypopharynx, lift epiglottis with blade tip expose vocal cords

•

The blade tip fits below epiglottis (not visible with blade in position)

•

Pass tube through cords into trachea so balloon just passes cords

•

Pressing posteriorly on anterior neck at larynx level helps bring an anterior larynx into view

•

BURP: Backwards, Upwards, to the Right, with

Pressure

•

Withdraw stylette

•

Ventilate with 100% O 2

•

Confirm tube position

•

Listen over stomach & BL chest

• • • • •

Fog in tube No epigastric sounds ETCO 2 (waveform after capnogram) Note position of tube at teeth Inflate the cuff with 10cc syringe

•

Tape, tape, tape!

•

Unconscious, No gag, Unconventional

•

Lift tongue, pull mandible forward

•

Slide middle & index fingers down tongue

•

Palpate epiglottis with middle finger

•

Slide ETT between tongue & finger under epiglottis into trachea

•

Anterior, difficult cord visualization

•

Angled tip “clicks” when passing through glottal opening onto trachea rings allowing ETT to be passed over it into the trachea

•

Thread ETT over bougie and advance it to a depth of 20-24 cm

•

Confirm ETT placement

•

Anticipated difficult airway, difficult BVM

•

Patient must be semi-alert / conscious

•

Contraindicated in uncooperative patients, coagulopathic, or head trauma

•

High secondary infection rate, often significant bleeding

•

Generous lubrication

•

Insert along floor of nasal cavity into hypopharynx

•

As patient exhales, gently & rapidly advance tube into trachea

•

Confirm placement

•

Variable sizes of traditional & intubating LMAs

•

Seals around glottic inlet

•

Downsides:

•

NOT a definitive airway

• •

High risk of aspiration Best for the OR

•

Upsides

•

Adult & pediatric sizes

•

Fairly simple to place

• • • • • • • •

Hyper oxygenate Check cuff Lubricate posterior cuff Head neutral or slightly flexed Insert following hard palate (use index finger to guide) Stop when met with resistance Inflate cuff until “rises” & secure Confirm & secure

•

Difficult or failed intubation, full stomach, neck trauma

•

PPE (patients cough in your face)

•

Open airway with laryngoscope

•

Wait for patient to cough or exhale – observe for bubbles or “white flash” indicating cords

•

Insert ETT & confirm

•

Unconscious, difficult airway, failed airway, primary

•

Blind insertion with neck in neutral position

•

Contraindicated if gag reflex, esophageal disease, ingested caustic substances

•

Anatomically shaped distal tip assists passage behind larynx into normally collapsed esophagus

•

Allows PPV >30cm H 2 O ventilation regardless of placement in esophagus or trachea

• • • • • • •

Choose size & test cuff Apply lubricant to beveled distal tip Hold King with right hand; open mouth & lift chin with left hand Rotate King so blue line touches corner of mouth; insert tip into mouth As tip passes tongue, rotate tube back to midline so that blue line faces chin Advance tube until base of connector aligned with gums Inflate cuff & confirm placement

•

More an ED / OR than EMS skill

•

Orally or nasally

•

Apply 2% lidocaine to oropharynx

•

Use oral airway to protect equipment

•

Introduce lubricated ETT in midline following base of tongue, pass uvula, behind epiglottis & between vocal cords until carina visualized

•

Advance until cords in center of visual field: Rotate, flex, advance, rotate, flex, advance until ETT tip 3-5 cm above carina

•

Remove scope, confirm airway

•

Alternative to direct laryngoscopy

•

Restricted oropharyngeal views

•

Airway obstructions

•

Nasotracheal intubation adjunct

•

Tube exchange

•

Educational

•

Open patient’s mouth & insert glidescope exactly as you would a laryngoscope

•

Watch video screen, not patient

•

When cords visualized, slide lubricated ETT alongside glidescope until visualized on screen passing cords

•

Remove handle, inflate cuff, confirm placement

•

Seldinger Technique

•

Wire through a needle

•

Downsides:

• • •

Difficult to perform Difficult to master Long procedure

•

Not an EMS skill

•

Locate cricothyroid membrane

•

Insert 16g needle in membrane midline at a 45 degree angle towards feet

•

After “pop” through membrane, advance needle 1 cm

•

Aspirate needle + catheter

•

Secure catheter & ventilate via BVM, or continue to surgical cricothyrotomy

•

Does not provide adequate ability to ventilate in the adult

•

Place patient supine with neck slightly extended

•

In-line stabilization if cervical trauma suspected

•

Locate cricothyroid membrane midline between thyroid cartilage (Adam’s apple) & cricoid cartilage

•

Prep overlying skin

•

Puncture cricothyroid membrane at 90° angle

•

Confirm needle entry into trachea by aspirating air

•

Change hand angle to 60°; slide catheter sheath forward to stopper hub level

•

Advance plastic cannula as you remove needle & syringe

•

If cuffed, inflate with 2-3cc

•

Begin ventilation when needle & syringe removed

• • • •

Cut 1.5-cm longitudinal midline incision over cricoid & thyroid cartilages Separate skin edges to see cricothyroid membrane Make a transverse stab incision through membrane into trachea Push scalpel handle into membrane opening & rotate 90 degrees

•

Use scissors to extend tracheal incision, tracheal hook to grab tracheal rings, & grasp skin edges with hemostats

•

Introduce 5.0-6.0 ETT into trachea with bevel pointed caudally to 1cm above endotracheal balloon, which is then inflated

•

Secure ETT

•

Ventilate patient, observing for chest rise & fall

•

Auscultate for BL breath sounds

•

If absent, ETT may be in neck subcutaneous fascia or esophagus

•

Remove & attempt to re-insert

•

Secure device

•

Continuous evaluation & documentation of oxygen saturation, ETCO 2 , vitals

•

Notify ED of Priority 1 patient

•

Direct Visualization

•

Lung Sounds

•

Tube Condensation

•

Colormetric capnography followed by continuous waveform ETCO 2 capnography

•

Pulse Ox improvement

•

Vital signs stabilization

46

• • • • • • • • • • • • •

Preoxygenate, BVM, Full O 2 2 large bore IV / IO & IVF tank Monitor 2 sizes ETT, checked cuffs, back-up Blade, checked light, back-up Alternative airway checked Handle, checked batteries, back-up Stylette, back-up Suction McGills ETCO 2 detector, back-up Syringe x 2 Manpower & tape

• • • • • • •

Maine Department of EMS. “Advanced Airway Training”. 2010 S Hopkins RN. “Equipment Review”. Condell Medical Center EMS System. 2008 Proulx A, MPAS, PA-C. “Airway Management in the Combat Casualty”. 2011 Emergency Medicine: A Comprehensive Study Guide, Tintinalli, 6 th ed, Mcgraw-Hill, 2004 www.myrusch.com

Ron Walls “Textbook Emergency Airway Management” (2011) Difficult Airway Site (www.theairwaysite.com

)

2 nd & 3 rd degree burns to face, OP, ear, scalp, nares, melted dental plate •

Know your anatomy

•

Know your options

•

Practice your options

•

Know when to say when!

1 month later!