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#3 Intro to EM Airway Management- Assessment and SupraGlottic Airways (SGA)

#3 Intro to EM Airway Management- Assessment and SupraGlottic Airways (SGA). Andrew Brainard. #3 SupraGlottic Airway. Learning Objectives : Briefly describe plan, assign roles Declare “ Crash Airway ” Skip checklist Continue Chest Compressions Place SupraGlottic Airway

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#3 Intro to EM Airway Management- Assessment and SupraGlottic Airways (SGA)

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  1. #3Intro to EM Airway Management-Assessment and SupraGlottic Airways (SGA) Andrew Brainard

  2. #3 SupraGlottic Airway • Learning Objectives: • Briefly describe plan, assign roles • Declare “Crash Airway” • Skip checklist • Continue Chest Compressions • Place SupraGlottic Airway • Proper sized LMA/AirQ • Proper insertion (<30sec) • Troubleshoot cuff leak • Tube confirmation • Discuss • Crash vs Emergent vs Semi-elective • Advantages/Disadvantages of SGAs • Indications for SGA, RSI, ETT • Safe removal of SGA • Formal Airway Assessment • MOANS/LEMON/RODS • Specific briefing for Plan A, B, C, & D • Suction • Leave Cuff Up • Remove under direct visualization • Bell in Short Stay: • 60y/o M, chest compressions in progress on patient admitted with chest pain • On floor unresponsive • GCS 3, No pulse, CPR in progress, • Unobtainable SaO2 • Difficulty with BVM seal (beard, small jaw, no neck, emesis, high resistance) • Crash SGA during compressions • Insert SGA • Oxygenate and Ventilate through SGA • Get ROSC • Transfer to resus • Intubate through SGA • Discuss removing SGA • Formal Airway Assessment • MOANS • LEMON • RODS • SHORT

  3. Using SuperGlottic Airways (SGA) Air Q • Indications • Predicting difficult (RODS) • Sizing • Insertion Procedure • Troubleshooting • Intubating through an SGA Fastrack I-LMA

  4. SGA/LMA SGA/LMA SGA/LMA • Indication(s) • Rescue Airway • Rescue Oxygenation • Anywhere on the Algorithm • Replacing Inadequate BVM • During CPR/compressions • For Pre-Oxygenation before Laryngoscopy (Rapid Sequence Airway) • After unsuccessful Laryngoscopy • Before/during cric SGA/LMA SGA/LMA SGA/LMA SGA/LMA

  5. Intubating LMA (Fastrack) #3- Small Adults 30-50kgs #4- Most Adults 50-70 kgs #5- Large Adults 70-100 kgs AirQ #1.0- Infant <7 kgs #1.5- Toddler 7-17 kgs #2.0- Child 17-30 kgs #2.5- Small Adult 30-50kgs #3.5- Most Adults 50-70 kgs #4.5- Large Adult 70-100 kgs Ideal Body Weight (height)

  6. Predictors of Difficult SGA • RODS • R: restricted mouth • O: obstruction • D: disrupted or distorted airway • S: stiff lungs or c-spine

  7. AirQ • Insertion • Lubricate • Leave red tag on pilot balloon • Lift tongue • Finger/Laryngoscope/Tongue depressor • Can use finger to assist around the corner • Jaw lift • Position incisors between 2 insertion marks • Add ~5 cc’s of air. • Minimizing Leaks • Neutral head position • Use jaw lift • Don’t over-inflate • Check position • While inflated, pull back 1-3cm • Change size • Check ETCO2 waveform How to use a AirQ http://www.youtube.com/watch?v=E0a1KYwfDk0(9 minutes)

  8. SupraglotticAirway (SGA) • Prepare/position airway • Lubricate and deflate cuff • Pull the jaw and tongue forward • Finger • Laryngoscope • Tongue depressor • Insert the LMA • Press against hard palate • Advance until resistance • Inflate the cuff • Poor seal may indicate over inflation. • Ventilate the patient with PEEP • Confirm placement • ETCO2 • Chest Rise • Listen for Leak

  9. Troubleshooting SGAs • Get best possible seal • Over-inflation is frequently the cause of leaks • Usually Too deep • Test airway pressures • Watch ETCO2 trace • Chandy maneuver, • Rotate • Sagittal • Coronal • Lifting • Toward ceiling

  10. Intubating through the LMA • Size ETT/I-LMA • Lubricate tube • Test ETT fit • Place LMA • Insert ETT • Reattach BVM to ETT • Ventilate w/ETCO2 • Advance ETT • Applying upward pressure on the LMA • Ventilate w/ ETCO2 • Advance ETT through cords • Verify placement • ETCO2 • Listen for leak • Removing the LMA is optional • Confirm placement • Ventilate w/ ETCO2 • Confirm tube placement • Inflate ETT cuff • Ventilate • Relax

  11. Airway briefing and checklist • CPR with chest compressions and BMV are in progress. • We are having difficulty assuring oxygenation with a BVM • This is a crash airway • Continue Chest Compressions • Place the I-LMA #5 • Continue Chest Compressions • Our plan is: • A- Continue to attempt to BVM • B- Place I-LMA #4 (now) • C- Direct/bougie/7.5 tube once we have ROSC or some more time • D- Cric if we get ROSC but can not get an airway • Questions? • Oxygenate the patient

  12. SuperGlottic Airways (SGA) • Indications • Predicting difficult (RODS) • Sizing • Insertion Procedure • Troubleshooting • Intubating through an SGA

  13. Brief SGA References: • Thomas C. Mort The Supraglottic Airway Device in the Emergent Setting: Its Changing Role Outside the Operating Room. Anesthesiology News, 2011- http://www.anesthesiologynews.com/download/sga_angam11.pdf(accessed on 15/6/2014) • Daniel J Cook, AirQ Tips and Techniques Youtube- Mercury Medical https://www.youtube.com/watch?v=E0a1KYwfDk0(accessed on 15/6/2014) • Dr. Gallagher’s Neighborhood- Laryngeal Mask Airway: MICU Fellows Airway Course- https://www.youtube.com/watch?v=-oXa-f5qkGY&index=5&list=PLDvE6n0oI4ehBbTL_OAMeFQvJmJFz6tGU(accessed on 15/6/2014) • Nichole Bosson- Laryngeal Mask Airway, Emedicine: http://emedicine.medscape.com/article/82527-overview#a15(accessed on 15/6/2014)

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