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AIRWAY MANAGEMENT DURING CRISIS SITUATION

AIRWAY MANAGEMENT DURING CRISIS SITUATION. Dr. Zahid Akhtar Rao MBBS; MCPS; FCPS; M.Sc. (Pain Med ) Associate Professor PNS Shifa / Bahria University Medical & Dental College; KARACHI. OBJECTIVES. Crisis situations Causes of Crisis situations Basic airway evaluation

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AIRWAY MANAGEMENT DURING CRISIS SITUATION

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  1. AIRWAY MANAGEMENT DURING CRISIS SITUATION Dr. ZahidAkhtarRao MBBS; MCPS; FCPS; M.Sc. (Pain Med) Associate Professor PNS Shifa / Bahria University Medical & Dental College; KARACHI.

  2. OBJECTIVES • Crisis situations • Causes of Crisis situations • Basic airway evaluation • Management plan for Anticipated difficult airway – Plan A, Plan B , Plan C & Plan D • Gallery of tools • The Expected & Unexpected Difficult Airway

  3. DEFINITIONof Crisis Situation American Society of Anesthesiologist (ASA) suggested (difficult to ventilate) • That when signs of inadequate ventilation could not be reversed by mask ventilation or oxygen saturation could not be maintained above 90%

  4. DEFINITION (difficult to intubate) • If a trained Anaesthesiologist using conventional laryngoscope takes more than 3 attempts or more than 10 minutes to complete tracheal intubation

  5. Pre-op assessment Equipments CAUSES OF CRISIS SITUATIONAnaesthesiologist Experience not enough Poor technique Malfunctioning equipment Inexperienced assistance

  6. CAUSES OF CRISIS SITUATION Patient • Congenital causes • Acquired causes

  7. Basic airway evaluation in all patients • Dr. Binnion’sLEMON Law • BONES • The 4 D’s

  8. Dr. Binnions Lemon Law: An easy way to remember multiple tests… • L ook externally. • E valuate the 3-3-2 rule. • M allampati. • O bstruction? • N eck mobility.

  9. L: Look Externally Obesity Buck teeth Short muscular neck Receding jaw Dentures

  10. L: Look Externally Macroglossia Stridor Facial trauma

  11. E:Evaluate the 3-3-2 rule • 3 fingers fit in mouth- Inter incisor distance • 3 fingers fit from mentum to hyoid cartilage • 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage

  12. M:Mallampati classification soft palate, fauces; uvula, anterior and the posterior pillars. the soft palate, fauces and uvula Class-I Class-II soft palate and base of uvula Class-III Only hard palate Class-IV

  13. O: Obstruction? • Blood • Vomitus • Teeth • Epiglottis • Dentures • Tumors • Impacted Objects

  14. N:Neck mobility -Measurement of Atlanto-Occipital Angle

  15. Thyro- Mental Distance • Measure from upper edge of thyroid cartilage to chin with the head fully extended. • A short thyromental distance = an anterior larynx . • > 7 cm is usually= easy intubation • < 6 cm=difficult airway

  16. MANAGEMENT PLAN OF ANTICIPATED DIFFICULT AIRWAY

  17. Is mask ventilation going to be difficult? Can’t ventilate Defined by “BONES” • Beard • Obesity • No teeth • Elderly • Snoring Can’t ventilate

  18. Is laryngeal visualization going to be difficult? Can’t intubate Defined by 4 D’s • Disproportion • Distortion • Dysmobility • Dentition

  19. Disproportion Achondroplasia Pierre robin sequence Can’t intubate Acromegaly Prognathism

  20. Distortion Burns contracture Neurofibromatosis Can’t intubate Cystic hygroma

  21. Dysmobility TM joint Ankylosis Can’t intubate Klippel Fiel

  22. Dentition Can’t intubate Edentulous Buck teeth

  23. Is cricothyroidotomy going to be difficult? Can’t Rescue • Should assessment reveal a potentially difficult airway the cricothyroid membrane should be identified and marked, BEFORE an intervention is undertaken

  24. Possible Options! Following airway assessment, the person performing the intubation should be in a position to decide between three possible options • Awake intubation • Quick look • Induction and paralysis

  25. 1. Awake Intubation The patient needs to be intubated awake There is significant risk of complications if sedatives and/or muscle relaxants are administered prior to airway control.

  26. 2. Quick Look The patient may be sedated for an attempt at direct laryngoscopy WITHOUT muscle relaxation (“Quick Look”) There is some risk of failed laryngoscopy but There should be a low risk of failed mask ventilation.

  27. 3. Induction & Paralysis The patient may be induced and paralyzed, In this case the patient is assessed as having a low risk of laryngoscopy and/or mask ventilation

  28. What are we going to do if we don’t get the Tube? • Plans “A”, “B” ,“C” and plan “D”. • Know this answer before you tube.

  29. Failure -Why does it happens? • No critical discussion with colleagues about proposed management plan • No request for experienced help • Exaggerated idea of personal ability • Ill-conceived plan A and/or plan B • Poorly executed plan A and/or plan B • Persisting with plan A too long, starting the rescue plan too late • Not involving, and preparing, surgical colleagues

  30. GALLERY OF TOOLS • Different types of airways • Combitube • ILMA/LMA • Video laryngoscopes • Light wand • Fibre-optic bronchoscope • Retrograde guided intubation • Cricothyroidotomy

  31. ANTICIPATED DIFFICULT AIRWAY ELECTIVE EMERGENCY

  32. ANTICIPATED DIFFICULT AIRWAY ANTICIPATED DIFFICULT AIRWAY ELECTIVE EMERGENCY

  33. ELECTIVE Old case of Hemi-mandibulectomy with forehead flap with trismus for block dissection of neck nodes

  34. Anesthesia of choice - G.A. Intubating technique of choice ?

  35. MANAGEMENT PLAN OF UNANTICIPATED SITUATION (DIFFICULT AIRWAY)

  36. TheUnexpectedDifficultAirway • Experienced help may not be immediately available • Special equipment may not be immediately available • A general anaesthetic has usually been administered • A long acting relaxant may have been given • Backup airway management plans may be poorly thought out

  37. Take home message • Be familiar with the alternative methods of intubating technique and use it regularly in your day today practice e.g. ILMA, FOB, Videolaryngoscopes, cricothyroidotomy……………. • So that you won’t fumble at the time of crisis

  38. GOOD LUCK Challenges may be Waiting for you

  39. Thank you

  40. EVEN WITH PROPER EVALUATION ! 15- 50% ARE ONLY PICKED UP

  41. DIFFICULT MASK VENTILATION DIFFICULT INTUBATION

  42. EXTREMELY DIFFICULT ABANDON GS – 1 in 2000 OBG- 1 in 300

  43. Pre-oxygenation: How Much Is Enough? Two techniques common in use: • Tidal volume breathing (TVB) of oxygen for 3–5 min • Deep breaths (DB) 4 times within 0.5 min Both are equally effective in increasing arterial oxygen tension (Pao2). Anesth Analg 1981; 60: 313–5

  44. Pre-oxygenation Spontaneous recovery from succinylcholine-induced apnea may not occur sufficiently quickly to prevent hemoglobin desaturation in subjects whose ventilation is not assisted. Each subject received 5 mg/kg thiopental and 1 mg/kg succinylcholine. Anesthesiology 2001, 95: 754-759

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