Transcript Slide 0
seventh edition International Trauma Life Support for Emergency Care Providers Airway Management CHAPTER 4 Airway Management Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Respiratory anatomy and physiology • Importance of observation • Supplemental oxygen, various airway adjuncts – Indications, contraindications, advantages, disadvantages International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Predictors of difficulty – Mask ventilation and endotracheal intubation • Sellick maneuver • Essential components of airway kit International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Initial Airway Management • Most important trauma care task – Challenging in field – Frequently time critical – Unpredictable – Need options and alternatives – Always start with basics Courtesy of Stanley Cooper, EMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Anatomy and Physiology International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Anatomy and Physiology • Nasopharynx – Delicate – Turbinates • Oropharynx – Hyoid bone • Hypopharynx – Epiglottis International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Anatomy and Physiology • Larynx – – – – – Pyriform fossa Laryngeal prominence Vocal cords Thyroid cartilage Cricoid cartilage ELM – Cricothyroid membrane ©Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Anatomy and Physiology ©Pearson Cricothyroid membrane International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians ©Pearson Anatomy and Physiology • Trachea, bronchi – Carina – Mainstem bronchi – Protective reflexes • Lungs – Pleural space – Alveolocapillary membrane International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Average Adult • Distances can vary by several cm ©Pearson ©Pearson • 2–2.5 cm movement in flexion/extension International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Patent Airway Without a patent airway, all other care is of little use. International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Patent Airway • Basic airway manuevers – Modified jaw thrust – Jaw lift (Courtesy of Buddy Denson, EMT-P) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Patent Airway • Continual observation • Suction with large-bore tubing • Airway adjuncts – Nasopharyngeal airway – Oropharyngeal airway – Blind insertion airway device (BIAD) – Endotracheal intubation International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Difficult Airway • Rapid sequence intubation (RSI) – Also called Drug Assisted Intubation (DAI) – BVM ventilation and immediate transport • Assessment of difficult airway – Remember MMAP M M A P Mallampati Measurement 3-3-1 Atlanto-occipital extension Pathology International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Remember Airway management can occur without RSI, but RSI cannot occur without airway management! International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians MMAP: Mallampati Score International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians MMAP • Measurement 3-3-1 – Chin to hyoid bone – Opening of mouth – Lower-jaw protrusion • Atlanto-occipital extension – Only if cervical-spine injury not suspected • Pathology – Anatomic airway obstructions International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Patent Airway Noisy breathing is obstructed breathing. International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Oxygenation • Normal oxygenation – PaO2: 100 mmHg • Pulse oximetry – Goal: maintain SpO2 >95% – Monitor SpO2 with all trauma patients – Monitor SpO2 with any respiratory compromise International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Supplemental Oxygen % Oxygen Device Flow Rate 40–50% Simple Face Mask 10–12 lpm 60–90% NRB Face Mask 12–15 lpm 25–30% Nasal Cannula 40–50% BVM 12–15 lpm 90–100% BVM with Reservoir Bag 12–15 lpm 100% FROPVD International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 2–6 lpm 40 lpm Normal Ventilation • Tidal volume (VT) – Amount moved with each breath – 400 to 600 cc (adult) • VT x breaths/minute = Minute volume – 500 cc x 12 breaths/min = 6 liters/min (adult) – Fast, shallow: 250 cc x 24 breaths/min = 6 liters/min – Slow, deep: 750 cc x 8 breaths/min = 6 liters/min International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Normal Ventilation • Normal ventilation – Carbon dioxide in blood (pCO2) 35–40 mmHg • Abnormal ventilation – Hypoventilation: pCO2 above 40 mmHg – Hyperventilation: pCO2 below 35 mmHg • Capnography – End-tidal CO2 (ETCO2) relates directly to pCO2 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians When in doubt, give oxygen! Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Positive Pressure • Ventilation rate – 10–12 per minute – 8–10 per minute Non-intubated patient Intubated patient • Supplemental oxygen essential • Suction must be immediately available – Avoid gastric distention • Monitor lung compliance International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Perfusion and Ventilation • Monitor effectiveness – Pulse oximetry (SpO2) monitors oxygenation Courtesy of David Effron, MD – Capnography (ETCO2) monitors ventilation Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Ventilation Techniques • Will be covered in the airway skill station ©Pearson Courtesy of Buddy Denson, EMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Difficult BVM Ventilation •B •O •O •T •S Beards Obesity Older patients Toothlessness Snores or stridor International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Airway Kit • Airway adjuncts – Various adjuncts – Intubation kit – Rescue airway device • Oxygen delivery – Cannula and masks – Pocket mask – BVM with reservoir bag • Portable suction • Monitoring devices – SpO2 – ETCO2 • Oxygen cylinder ©Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Summary • Ensuring a patent airway is essential – Need a clear understanding of anatomy, tidal volume, minute volume, compliance – Must be proficient in various techniques – Equipment must be immediately available • When in doubt—give oxygen! International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians