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Portex Surgical Airway

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If the patient cannot be ventilated due to a suspected life ... Whispers when he talks, No stridor. Chest: Clear. What do you suspect? How would you manage him? ... – PowerPoint PPT presentation

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Title: Portex Surgical Airway


1
Portex Surgical Airway
  • SOCPC Winter 2007 CME

2
Objectives
  • Indications
  • Conditions
  • Contraindications
  • Anatomy
  • Equipment
  • Procedure
  • Complications
  • Needle Cricothyrotomy

3
Indications
  • If the patient cannot be ventilated due to a
    suspected life-threatening upper airway
    obstruction AND
  • The patient requires intubation AND
  • Cannot be intubated OR
  • Ventilated
  • PATCH for the Order to insert a PORTEX
    Cricothyrotomy

4
Conditions
  • Age gt12
  • Weight gt 40 kg
  • Patch for orders for a needle cricothyrotomy

5
Contraindications
  • Suspected fractured larynx
  • Inability to locate the cricothyroid membrane
  • PATCH - consider needle cricothyrotomy

6
Causes of Unresolved Upper AW Obstruction
7
(No Transcript)
8
If there are steps you can take to treat the
patient without a cricothyrotomy
  • DO THOSE FIRST

9
Case 1
  • 80 year old man taken to a Steakhouse for his
    birthday
  • Witnessed choking on meat
  • Collapses unconscious
  • You are the ACP Crew en route
  • How will you plan to manage the airway?

10
Conscious FB Obstruction
  • If they are conscious you can consider the
    Heimlich maneuver
  • Minimize on scene time
  • Alert the hospital

11
Unconscious FB Obstruction
  • LOOK in mouth,
  • LOOK with a laryngoscope, and have Magills in
    hand
  • Have partner do chest thrusts as this may push
    the FB up towards you (some gentle abdominal
    pressure may help)
  • Minimize scene time and alert the hospital

12
Case 2
  • 53 year old gentleman with the worst sore throat
    he has ever had for the past 3 days
  • Saw his GP yesterday was put on penicillin but
    much worse today
  • Past History Neg
  • Hurts to swallow, T 39, No cough
  • Whispers when he talks, No stridor
  • Chest Clear
  • What do you suspect? How would you manage him?

13
Case 2 continued
  • Epiglottitis
  • We dont see it in kids any more. Why?
  • Sit this man up and give him blow by 02 if he
    needs it
  • If you needed to intubate him how would you
    prepare your ETTs?
  • If you were unsuccessful, what procedure would
    save his life?

14
Case 3
  • 26 year old patient involved in car accident
  • Struck their anterior neck on steering wheel
  • On crew arrival patient is unable to speak
  • What do you think is injured?
  • Crew puts him on a back board with a collar which
    immediately makes patient combative

15
Case 3 continued
  • He fractured his larynx
  • Why is lying on his back making him combative?
  • How can this patient be positioned while keeping
    his C-spine protected?
  • What are your options for airway management in
    this situation?
  • What could you consider?

16
Case 4
  • Severe Facial Burns need intubation but seldom a
    cricothyrotomy
  • Why?
  • Burn patients that resists intubation may be a
    candidate for facilitated intubation
  • If they are unconscious, and you plan to
    intubate, do it orally with downsized tubes ready
    and dont cut them. Why?

17
Cricothyrotomy
  • ANATOMY REVIEW

18
What you cant see you feel
19
What you see and feel
  • Skin
  • Where is the thyroid notch?
  • Platysmal muscle

20
Structures to avoid
21
Structures you will feel
  • Thyroid Gland
  • Muscle

22
Deep Structures of Neck
  • The notch on the thyroid cartilage is the
    easiest landmark to identify, especially in thin
    males
  • The cricothyroid membrane is ultimately the space
    you want to find

23
The Portex Airway
24
Plastic Clamshell Kit
25
Contents
ETT tie
thermovent T
6mm cuffed ETT
scalpel
veress needle
Suture- keep but dont use
syringe
gel
26
Veress Needle
  • Fig (a) spring loaded silver needle in a white
    plastic dilator
  • Fig (b) Proper Grip
  • Fig (c) Red warning flag appears when needle tip
    meets resistance
  • Cricothyroid membrane AND back of trachea

27
Procedure
  • Don PPE
  • Open Kit
  • Sterile technique
  • Check and lubricate cuff
  • Position patient supine, with neck slightly
    extended
  • (use C-spine precautions if necessary)

28
Palpate the Landmarks
  • Palpate for the notch at the top of the thyroid
    cartilage
  • Feel down to the bottom of the thyroid cartilage,
    and you will touch the cricothyroid membrane in a
    small depression

29
Prep area and make incision
  • 2 cm horizontal incision over the cricothyroid
    membrane
  • THROUGH SKIN ONLY

30
Insert the needle
  • Insert the needle PERPENDICULAR to the neck
  • You will see the red indicator flag as you
    push through the cricothyroid membrane

31
When the red indicator flag disappears
  • You are IN the trachea

32
Carefully keep going until the red flagre-appears
  • When the red flag reappears
  • You are touching the back of the trachea with the
    Veress needle
  • DO NOT ADVANCE ANY FURTHER or you will go through
    the posterior tracheal wall

33
Direct the needle towards the feet 45 degrees
  • When the red bar disappears you are in the
    tracheal lumen and the needle is no longer
    touching the posterior tracheal wall

34
Remove the needle
35
Slide ETT off dilator into trachea without
advancing the dilator
36
Inflate cuff
  • Secure using provided tie
  • Confirm placement by auscultating as ventilate,
    AND ETCO2
  • Watch chest rise and fallwith smaller ETT may
    require longer exhalation time

37
Potential Complications
  • Penetration of posterior wall of trachea
  • Bleeding
  • Tissue swelling of surrounding structures
  • Damage to the larynx
  • Injury to the thyroid and parathyroid glands
  • Inadequate ventilations
  • Aggressive ventilations Barotrauma subcutaneous
    emphysema, pneumothorax

38
What if you have a contraindication?
  • Fractured Larynx
  • Inability to Landmark
  • Age lt12
  • Weight lt40kg

39
PATCH
Consider Needle Cricothyrotomy
40
Needle Cricothyrotomy
41
Equipment
  • Syringe
  • 14 G 1.25 inch
  • Filter
  • 15 mm adapter off a 3.0 ETT

42
Landmark
Feel for cricothyroid membrane
Palpate top of thyroid cartilage
43
Sterile Technique
44
14 g IV cath with syringe attached
Puncture skin, 45 degree angle towards feet
Stabilize thyroid cartilage
45
Aspirate as you advance needle
  • When you have a loss of resistance and get air
    you are in the trachea
  • Advance 2-3 mm more to insure tip of catheter is
    in and not just needle tip

46
Slide Catheter off needle
47
Attach BVM
  • 15 mm adapter off a 3.0 ETT fits the end of the
    14 G needle
  • Bag with short brisk compressions of BVM
  • Watch chest rise
  • Allow additional time for fall or exhalation

48
Why consider needle cric for these?
  • Fractured Larynx
  • Swelling or uncertain anatomy

49
Limitations of Needle Cricothyrotomy
  • Although you can oxygenate relatively well, C02
    rises you have 20-30 minutes to get definitive
    care
  • Small opening in 14 G, need relatively high
    pressure to ventilate, have to be careful not to
    cause barotrauma
  • Need longer exhalation time or will get air
    trapping and barotrauma

50
Complications
  • Subcutaneous emphysema and barotrauma
  • Bleeding
  • Inadequate oxygenation

51
Questions?
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