Pre-hospital and ER Management of Difficult Airway in Trauma Patient

1
Pre-hospital and ER Management of Difficult
Airway in Trauma Patient

• ??.????????? ???????????
• ??.???????

2
Airway Decision Scheme
3
(No Transcript)
4

• ????????????????suction, O2 , laryngoscope,
  LMA , surgical /needle cricothyroidotomy
  protect C-Spine Preoxygenate
• 
  No
• ???????????????????????????
  Definitive airway / Surgical airway
• Yes
  
  Difficult
• ??????????????????????????????????? LEMON
• Easy
• ??????????????????????? cricoid pressure
  ???????????????
• Unsuccessful
  
• ??????????????????? ( LMA, LTA,GEB)
  awake intubation
• ????????? Definitive airway/ Surgical airway

5
Encountered Difficult Airway algorithm
6
(No Transcript)
7

• ????????????????????????????????????
  ???
• ????? bag mask ventilation ( BMV)
• ???????1 ??????????????????????????????
  ??????
• ???????2 ??????????????????????????????
  ?????????
• 
  

8

• ???????1 ????????????????????????????
  ????????
• ??????????????
  ??????????????????
• ???????????????????????
  ??????
• best look, ??????????? blade,??? alternative
  intubation techniques
• 
  ????????????
• ???????????????? BMV
  ??????????

9

• 
  ????????????
• ????????????????????????????
  ?
• ??????????????????????? , alternative
  intubation techniques
• 
  ????????????
• ??????????????????????????????????????????
  (failed intubation)
• ???????????? BMV ????
  EGD

10

• ???????2 ????????????????????????????
  ???????????
• ????????????????????????
  ???
• ???? Failed Oxygenation ( Sat lt90
  ?????? BMV )
• ???????????????????
  cricothyrotomy
• ???????????? EGD
  ????????????????????
• 
  ????????????
• ????????? EGD ???????????????????
  ?
• ???????? cricothyrotomy???????
  ??????
• 
  

11

• ??????????????????????????????
  ???????????
• ??????????????????????????????????????????
  ????????????? ???????? definitive care
• ?????????????????????????????????????????
  ????
• 
  

12
???????

• 1) Airway
• - ?????????????????????????????????
• - ????????????????????????????????????????
  ??????????
• 2) Ventilation
• - ?????????????????????????????????????????
  ?

13
???????

• 3) Airway Management
• - Chin-Lift Maneuver - Jaw-Thrust
  Maneuver
• - Oropharyngeal Airway - Nasopharyngeal
  Airway
• - Laryngeal mask Airway - Gum Elastic
  Bougie
• - Definitive airway

14
???????

• 4) Difficult intubation
• - LEMON
• - Airway Decision Scheme
• - Technique for rapid sequence intubation (
  RSI)
• - Surgical Airway

15
Airway
16
?????????????????????????????
17
(No Transcript)
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?????????????????????????????

• 1 ) Look
• ? ????????????????????????
• ? ??????????????????????????????????????????????
  ????????
• ? ?????????????????????????????????? /
  ???????????
• ? ?????????????

19
?????????????????????????????

• 2) Listen
• ? ??????????????????????????? ????????,
  ??????????
• ? ????????
• 3) Feel
• ? ????????????????????????????????????????????
  

20
?????????????????????????????

• ????????????????????????????????
  ?????????????
• ??????????????????

21
?????????????????????????????????????????
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Maxillofacial Trauma

• Trauma to the midface
• ? ?????????????????????????????? nasopharynx
  ???? oropharynx
• ??????????? , ????????????????????????????

23
Maxillofacial Trauma

• Fracture of mandible
• ? ??????????????? bony fracture
  ????????????????????
• ????????????????????????????
• ? ???????????????????????????????????????
  ?????????????????????? ??????????????????????????
  ??????? ????????????

24
Neck Trauma

• Penetrating injury
• ? ??????????????????????? ??????????????????????
  ???????

25
Neck Trauma

• Blunt injury
• ? ?????????????????????????????? larynx ????
  trachea
• ??????????????????????
• ???????????????? tracheobronchial tree

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Neck Trauma

• ???????????????????????
• ???????????????
• fails
• 
  
• surgical airway

27
Laryngeal Trauma

• Clinical signs ??????????????????????????????????
  ???? larynx
• 1) Hoarseness
• 2) Subcutaneous emphysema
• 3) Palpable fracture

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Laryngeal Trauma

• ??????????????????????????? airway obstruction
• ?????????????????????????????????
  ????????????????????????? , jugular vein, carotid
  artery
• ???????????????????????? ? CT

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Ventilation
30
????????????????????????????????
31
????????????????????????????????

• Look
• ? ?????????????????????????
• ? ?????????????????????????????
• ? ????????????????????
• ? ?????????????????????? ?????????????
  ?????????????????????????? ??????????

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????????????????????????????????

• Look
• ? ???????????????????????????????
• ? ????????????
• ? ??????????????????????????????????????????????
  ??????????????
• ????????????????????????????

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????????????????????????????????

• 2) Listen
• ? ??????????????????????????????????????????????
  ????????

34
????????????????????????????????

• 3) ?????? pulse oximeter
• ? ??????? oxygen saturation ??? peripheral
  perfusion
• ? ?????????? ventilation

35
????????????????????????????????

• 4) Feel
• ? ?????? trachea shift
• ? ??????????
• ????????????????
• subcutaneous emphysema

36
?????????????????? (Ventilation)???????????????
?????????
37
Rib Fracture

• 
  ????????????
• ????????????????
• ?????????????????????
  ?

38
Intracranial Injury

• ??????????????????????
  ???
• ???????????????????
  ?????
• ???????????????????
  ???

39
Cervical Spinal Cord Injury

• ?????????????????????????????????????????
• ??????????????????????

40
Complete Cervical Cord Transection

• ?????????????????????????? phrenic nerves( C3
  ??? C4)
• ?????????????????????????????
• ?????????????

41
Airway Maintenance techniques
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Chin-lift Maneuver
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(No Transcript)
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Jaw-thrust Maneuver
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(No Transcript)
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Orophayngeal Airway
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(No Transcript)
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Orophayngeal Airway

• ?????????????????????????? ???????? gag reflex
  ???? cough reflex
• ?????????????????
• tip ? corner of mouth
• flange ? angle of mandible

49
(No Transcript)
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Pitfall
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Nasopharyngeal Airway
52
(No Transcript)
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Nasopharyngeal Airway

• ?????????? conscious semiconscious
• ????????????????????? ? ??????????????????????
• ??????? ? ???????? - ??????

54
Pitfall
55
Extraglottic device (EGD)
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Extraglottic device (EGD)

• ??????????????? supraglottic devices
• ????????????????????????????????????????
• vocal cord
• ?????????????????????????????????????????????????
  ????????????????????????? vocal cord

57
Extraglottic device (EGD)

• ?????? Laryngeal mask airway, Combitube ,
  Laryngeal Tube Airway
• ?????????????? failed intubation
• ? ???????????????????????????????
• ? ?????????????????????? EGD
• ?????????????????????????????? definitive
  airway ????

58
Laryngeal Mask Airway
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(No Transcript)
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(No Transcript)
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The Esophageal-Tracheal Combitube ( ETC)
62
(No Transcript)
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Laryngeal Tube Airway
64
(No Transcript)
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Alternative Intubation Techniques
66
Alternative Intubation Techniques

• ??????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????????????????
• ???????????????????????????????????????????????
  best look ? ????????????????????????????????????
  ????????????? ????????? alternative intubation
  techniques ?????

67
LMA Fastrach
68
(No Transcript)
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Lightwand ( e.g.Trachlight)
70
(No Transcript)
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Videolaryngoscopy( e.g.Glidescope)
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(No Transcript)
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Definitive Airway
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Definitive Airway

• Orotracheal tube
• Nasotracheal tube
• Surgical airway
• - cricothroidotomy
• - tracheostomy

75
Manual in line stabilization
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Surgical Cricothyroidotomy
77
(No Transcript)
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(No Transcript)
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(No Transcript)
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????????????????? definitive airway
81
????????????????? definitive airway

• ??????? apnea
• ????????? maintain airway patent
• ???????????????? aspiration
• ?????????????????????????????
• - inhalation injury
• - facial fracture
• - retropharyngeal hematoma

82
?????????????????

• 5.Closed head injury ??? (Glasgow Coma score lt
  8)
• 6. ??????????? oxygenation ?????????????? face
  mask
• ?????????????????????? cervical spine
  

83
LEMON Assessment for Difficult Intubation
84
LEMON assesment for difficult intubation

• LEMON
• L ? look externally
• E ? evaluate the 3-3-2 rule
• M ? mallampati
• O ? obstruction
• N ? neck mobility

85
L Look externally

• ??????????????????????????????????????????????????
  ??????

86
E Evaluate the 3-3-2 rule

• ???????????????incisor ? ?????????? 3 finger
  breaths (???????????????? )
• ??????????????? hyoid bone ??? chin? ?????????? 3
  finger breaths
• ??????????????? thyroid notch ??? floor of mouth?
  ?????????? 2 finger breaths

87
(No Transcript)
88
Mallampati Airway Classification

• Class 1? soft palate, uvula, fauces, pillars
• Class 2? soft palate, uvula, fauces visible
• Class 3? soft palate ,base of uvula visible
• Class 4?hard palate only visible

89
(No Transcript)
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Obstruction

• ??????????????????????????????????????????????????
  ???? laryngoscopy ??? ventilation ????????
• ???????? epiglottitis, trauma

91
Neck Mobility

• ??????????????????????????????????????????????????
  ????
• ???????????????????????????????

92
Rapid Sequence Induction
93
(No Transcript)
94
????????????

1. ????????????????????? surgical airway ????????
2. ?????? suction ambu-bag
3. ??? 100 ??????????????????
4. ?? cricoid cartilage
5. ????? induction drug ?etomidate 0.3 mg ?????????
   sedate

95
Sellick maneuver
96
????????????

1. ??? succinylcholine 1-2 mg/kg
2. ??????????????????????????????????????????????????
   
3. Blow cuff ?????????????? CO2
4. ???????????????? cricoid pressure
5. ????????????????

97
Components Of BEST LOOK Laryngoscopy
98
Sniffing Position
99
Sniffing Position

• ?????????????????????? cervical spine ???
  thoracic spine ???????????? atlantoocipital
• ??????????????????????????????????? 7-10
  ???????????????????
• ????????????? ?????? oral cavity, pharynx, larynx
  ????????????????????????? glottis ???

100
(No Transcript)
101
BURP Maneuver
102
BURP Maneuver

• ??? technique ???????laryngeal manipulation
  ???????????????? vocal cord ??????
• B ? Backward
• U ? Upward
• RP? Rightward Pressure

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(No Transcript)
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Laryngoscope Blade
105
Laryngoscope Blade

• Blade ??????? ( Miller)
• ??????? blade ?????????? epiglottis
• ?????????????????

106
Laryngoscope Blade

• Blade ???????? ( Macintosh)
• ??????? blade ?????? vallecular
  ???????????
• epiglottis
• ????????????????

107
Gum Elastic Bougie
108
Gum Elastic Bougie
109
Airway Management
110
Airway Decision Scheme
111
(No Transcript)
112

• ????????????????suction, O2 , laryngoscope,
  LMA , surgical /needle cricothyroidotomy
  protect C-Spine Preoxygenate
• 
  No
• ???????????????????????????
  Definitive airway / Surgical airway
• Yes
  
  Difficult
• ??????????????????????????????????? LEMON
• Easy
• ??????????????????????? cricoid pressure
  ???????????????
• Unsuccessful
  
• ??????????????????? ( LMA, LTA,GEB)
  awake intubation
• ????????? Definitive airway/ Surgical airway

113
Encountered Difficult Airway algorithm
114
(No Transcript)
115

• ????????????????????????????????????
  ???
• ????? bag mask ventilation ( BMV)
• ???????1 ??????????????????????????????
  ??????
• ???????2 ??????????????????????????????
  ?????????
• 
  

116

• ???????1 ????????????????????????????
  ????????
• ??????????????
  ??????????????????
• ???????????????????????
  ??????
• best look, ??????????? blade,??? alternative
  intubation techniques
• 
  ????????????
• ???????????????? BMV
  ??????????

117

• 
  ????????????
• ????????????????????????????
  ?
• ??????????????????????? , alternative
  intubation techniques
• 
  ????????????
• ??????????????????????????????????????????
  (failed intubation)
• ???????????? BMV ????
  EGD

118

• ???????2 ????????????????????????????
  ???????????
• ????????????????????????
  ???
• ???? Failed Oxygenation ( Sat lt90
  ?????? BMV )
• ???????????????????
  cricothyrotomy
• ???????????? EGD
  ????????????????????
• 
  ????????????
• ????????? EGD ???????????????????
  ?
• ???????? cricothyrotomy???????
  ??????
• 
  

119

• ??????????????????????????????
  ???????????
• ??????????????????????????????????????????
  ????????????? ???????? definitive care
• ?????????????????????????????????????????
  ????
•