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CAP – Module 4 DIFFICULT AIRWAY MANAGEMENT

CAP – Module 4 DIFFICULT AIRWAY MANAGEMENT. GHEMS_V11292018. Objectives. Review Anatomy and Physiology Review the approach to the difficult airway Review the protocols associated with difficult and failed airway management Review the difficult and failed airway algorithms. A&P Review.

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CAP – Module 4 DIFFICULT AIRWAY MANAGEMENT

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  1. CAP – Module 4DIFFICULT AIRWAY MANAGEMENT GHEMS_V11292018

  2. Objectives • Review Anatomy and Physiology • Review the approach to the difficult airway • Review the protocols associated with difficult and failed airway management • Review the difficult and failed airway algorithms

  3. A&P Review • Upper airway • Nasopharynx • Oropharynx • Laryngopharynx • Larynx

  4. A&P Review • Glottic structures • Glottic opening • Vocal cords • Cuneiform cartilage • Corniculate cartilage Together make up the Arytenoid Cartilage

  5. A&P Review • Laryngeal landmarks • Thyroid cartilage • Cricothyroid membrane • Cricoid membrane • Thyroid gland

  6. Airway Management – Difficult Airway • Indications: All Prehospital airways should be considered difficult to some degree. The provider must have preexisting criteria for predicting possible difficult airway situations and a set algorithm based on agency resources and County protocols for managing the difficult airway. • Critically ill patients will de-saturate quickly, possibly resulting in a failed airway situation.

  7. Airway Management • Approaching the Difficult Airway • Predicting • Use the LEMONpneumonic • L - Look Externally • E - Evaluate with 3-3-2 rule • M - Mallampati score • O - Obstruction • N - Neck mobility

  8. Look Externally For every patient who may require intubation, the paramedic should always look for readily apparent, even cosmetic, characteristics that may predict a potentially difficult airway. These include among others; obesity, micrognathia, evidence of previous head and neck surgery or irradiation, presence of facial hair, dental abnormalities (poor dentition, dentures, large teeth), a narrow face, a high and arched palate, a short or thick neck, and facial or neck trauma.

  9. External look

  10. 3-3-2 Rule

  11. Mallampati Score • Mallampati, Cormack and Lehane scores

  12. Obstruction • Foreign body • Trauma • Swelling • Esophageal spasms • Growth • Infection

  13. Obstruction list discussion • Foreign body – remove by direct laryngoscopy and Magill forceps • Trauma – Follow protocols and airway algorithms • Swelling – Follow protocols and airway algorithms • Esophageal spasms – Use of Succinylcholine • Growth – Follow protocols and airway algorithms • Infection – Follow protocols and airway algorithms

  14. Neck Mobility • Arthritis • Spinal immobilization • Location of patient Entrapment – discuss possibilities

  15. Decision Making • Question One • Is VentilationAdequate or Inadequate? • Question Two • Is the AirwayNormal or Disrupted?

  16. Decision Making: Ventilation Adequate Inadequate • SaO2 > 90% • Also note respiratory rate, effort • EtCO2 spot reading may be unhelpful (e.g. CO2 retainers) • SaO2 < 90% • Note baseline may be below 90% • Also note respiratory rate, effort

  17. Decision Making: Airway Normal Airway Disrupted Airway • Still identified as technically difficult • Anatomy intact • Examples: • Obesity • Anterior glottis • Small mouth • Still identified as technically difficult • Abnormal anatomy • Examples: • Trauma/burn • Infection • Hematoma • Cancer • Foreign body

  18. Decision Making: Resources Supraglottic Infraglottic • Combitube PROC 120 • Eschmann catheter (“bougie”) PROC 100 • Percutaneouscricothyrotomy (Ruschquicktrach) PROC 290 • Surgical cricothyrotomy PROC 290

  19. Airway Management – Difficult Airway • Approaching the Difficult Airway • Call for additional assistance • Maximize your chances • Position, medications, dentures out if needed • Have a PLAN • BVM/airway adjuncts • RSI • Partner tries or second try with different blade • ET introducer “Eschmann catheter” • Multi-Lumen Airway “combitube”

  20. Difficult Airway Algorithm Call for additional assistance Move to failed airway algorithm No Able to BVM Pt w/adjuncts Yes Follow post intubation protocol Yes RSI completed No Try with a different blade/partner tries RSI completed Yes No Yes Use Eschmann Catheter RSI Completed No Move to failed airway algorithm

  21. Airway Management – Failed Airway • Indications: provider is unable to secure a definitive airway. • Definition • Oxygen saturation is below 90% after one attempt at ETT OR • Three failed attempts at ETT • Management • Combitube: bridging airway until definitive airway is placed • Cricothyrotomy: surgical airway is definitive, non-surgical (e.g. “quicktrach”) is not

  22. Failed Airway Algorithm Call for assistance Failed Airway criteria met Cricothyrotomy No Able to BVM patient? Yes Consider Combitube No Time allows and successful? Yes No Able to maintain SpO2>90% Yes Arrange for definitive Airway Management

  23. Airway Management Questions?

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