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Airway Management

Airway Management. Airway Anatomy. Soft palate. Hard palate. Nasopharynx. Tongue. Oropharynx. Hypopharynx. Thyroid cartilage. Airway Anatomy. Hyoid bone. Thyroid cartilage. Cricoid cartilage. Trachea. Cricothyroid membrane. Airway Anatomy. Vallecula. Epiglottis.

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Airway Management

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  1. Airway Management

  2. Airway Anatomy Soft palate Hard palate Nasopharynx Tongue Oropharynx Hypopharynx Thyroid cartilage

  3. Airway Anatomy Hyoid bone Thyroid cartilage Cricoid cartilage Trachea Cricothyroid membrane

  4. Airway Anatomy Vallecula Epiglottis True vocal cords False vocal cords Cuneiform cartilage (arytenoids) Pyriform sinus Corniculate cartilage (arytenoids)

  5. Airway Anatomy Trachea Carina Bronchi

  6. Airway management tools • Chin lift / jaw thrust (most basic) • BVM • Airway adjuncts: oral, nasal • Non-visualized advanced airways (supraglottic) • Laryngeal Mask Airway (LMA) • Laryngeal Tube (ie. King LT) • E-T Combitube (dual lumen) • Endotracheal intubation (by various means) • Cricothyrotomy(most advanced) CONTINUUM IN WHICH ALL ARE IMPORTANT

  7. Airway management Visualization axis

  8. Prehospital decision to intubate Maintaining airway? Airway manuevers, Adjuncts no Now maintained? Intubate yes yes no no Coma cocktail successful? Protecting airway? yes yes no BVM, intubate Ventilating / oxygenating adequately? Coma cocktail, supp. O2 successful? no no yes yes Deterioration / airway compromise likely? Consider intubation vs. close observation Rapid transport yes no Supp. O2, Observe, Transport

  9. Difficult airways • “The difficult airway is something one anticipates; the failed airway is something one experiences.” - Ron Walls

  10. Difficult BVM - MOANS • Mask Seal • Facial hair, deformity, blood • Obesity / Obstruction • Cancer, lesions, excess tissue • Age • >55, higher risk of poor BMV • No teeth • Teeth keep face from caving in during BMV • Stiff / Snoring • Lung resistance issues (edema, COPD)

  11. Difficult Intubation - LEMON • Look externally • Evaluate 3-3-2 ideal • 3 fingers in open mouth (mouth opening size) • 3 fingers chin to hyoid (size of tongue in relation to pharynx) • 2 fingers hyoid to thyroid cartilage (larynx in relation to tongue base) • Mallampati score

  12. LEMON - Mallampati Best Worst

  13. LEMON • Obstruction • Known issues (hematomas, cancers, etc) • Muffled voice, stridor, or difficulty swallowing • Neck mobility • Inability to line up axis will make more difficult

  14. Failed airway • Definition: 1. unable to intubate by multiple attempts • or: 2. failure to intubate and oxygenation cannot be maintained • Need to decide which situation is in place: • Can’t intubate, can ventilate – go with the basics • Can’t intubate, can’t ventilate – go with the cricothyrotomy

  15. Review of intubation • Setup for intubation (already being ventilated with BVM) • Stylet • Endotracheal tubes (multiple sizes) • Average male: 8.5 mm average female: 7.5 mm (8.0 and 7.0 commonly used in EMS) • Laryngoscope and blades (curved and straight, multiple sizes) - check light • Syringe for inflation of balloon • Suction • Alternate airway devices • Verification method (colorimetric, capnograph, stethoscope) • Securing device

  16. Steps of intubation • Laryngoscope in left hand, loose grip with fingers • Position the airway (initially sniffing position if possible) • Open the mouth with right hand • Insert blade on far right side • Swing to the midline, moving tongue to the left • Upward pressure in the direction of the handle to expose the vocal cords (no levering) • Keep visual contact with vocal cords while obtaining ET tube

  17. Steps of intubation • Insert tube from right corner of mouth (bevel horizontal) • Rotate 90 degrees (bevel vertical) and insert through the vocal cords at midline until balloon passes completely through • Remove laryngoscope • Remove stylet (hold your tube!) • Inflate balloon with 7 – 10 mL of air • Ventilate and verify the tube by multiple means • Secure the tube

  18. Intubations http://www.youtube.com/watch?v=mvWUcP7LFMo http://www.youtube.com/watch?v=4V_pouIbcnA

  19. Verification of tube placement • Auscultation (stomach first?) – bilateral to check depth • Chest rise • Esophageal detection device • Colorimetric ETCO2 device • Continuous waveform capnography (“the most reliable method”) • Record depth at teeth (average 21 cm in females, 22-23 cm in males)

  20. Laryngoscopy techniques Cormack-Lehane grading system

  21. Laryngoscopy techniques • BURP manuever (similar but different from Sellick’smanuever or cricoid pressure) • Backward • Upward • Rightward (patient’s right) Pressure • Tends to improve the Cormack-Lehane grade • Assistant may provide too much pressure, so you can guide them

  22. Laryngoscopy techniques • Intubatingstylets (Bougie) • Using laryngoscope, insert flexible stylet between vocal cords (grade 2) or above the arytenoids (grade 3) • Slide ETT over the stylet into the trachea while keeping laryngoscope in place

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