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Basic Emergency Airway Management Pat Melanson,MD


Basic Emergency Airway Management Pat Melanson,MD Objectives Differentiate the Emergency Airway from elective intubation in the OR Assessment of airway compromise ... – PowerPoint PPT presentation

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Title: Basic Emergency Airway Management Pat Melanson,MD

Basic Emergency Airway ManagementPat Melanson,MD
  • Differentiate the Emergency Airway from elective
    intubation in the OR
  • Assessment of airway compromise
  • Indications for airway intervention
  • Recognition of the difficult airway
  • Bag-Mask Techniques
  • Laryngoscopy

Emergency Airway Management Unique
  • Full stomach - high aspiration risk
  • Altered level of consciousness
  • Deteriorating cardiorespiratory physiology -
    (hypotension, hypoxia)
  • Abnormal or distorted upper airway anatomy
  • No time for pre-op assessment

Airway Assessment
  • Assessment for airway compromise or threats and
    need for interventions
  • Examination for the potentially difficult airway

The Three Pillars of Airway Management (
Assessment of Compromises or Threats )
  • Patency of Upper Airway
  • ( airflow integrity )
  • Protection against aspiration
  • Assurance of oxygenation and ventilation

Indications for Active Airway Intervention
including intubation
  • Failure to maintain patency
  • Protection from aspiration
  • Hypoxic/ hypercapnic respiratory failure
  • Airway access for pulmonary toilet, drug
    delivery,therapeutic hyperventilation
  • Intractable Shock
  • Anticipated clinical deterioration

Indications for Intubation
  • Is there failure of airway maintenance ?
  • Is there failure of airway protection ?
  • Is there failure of oxygenation or ventilation?
  • What is the anticipated clinical course ? (i.e.,
    expected deterioration, long transport, long time
    in radiology, etc.)

Clinical Signs of Airway Compromise Threatened
  • Inspiratory stridor
  • Snoring ( pharyngeal obstruction )
  • Gurgling ( blood/ secretions )
  • Drooling ( epiglottitis )
  • Hoarseness ( laryngeal edema/ vocal cord
  • Paradoxical chest wall movement
  • Tracheal tug
  • Mass - abscess, hematoma, angioedema

Clinical Signs of Airway Compromise Inadequate
  • Blood in upper airway
  • Pus in upper airway
  • Persistent vomiting
  • Loss of protective airway reflexes
  • swallowing reflex is superior to gag reflex

Clinical Signs of Airway CompromiseOxygenation
and Ventilation
  • Central cyanosis
  • Obtundation and diaphoresis
  • Rapid shallow respirations
  • Accessory muscle use
  • Retractions
  • Abdominal paradox

Clinical Signs of Airway CompromiseOxygenation
and Ventilation
  • The assessment of oxygenation and ventilation is
    a clinical one.
  • Arterial blood gases should not be relied upon to
    assess whether intubation is necessary.

Techniques for the Compromised Airway
  • Head Positioning
  • Jaw Thrust, Chin lift
  • Orophryngeal/ Nasopharyngeal airways
  • Bag-Valve-Mask Ventilation
  • Endotracheal Intubation
  • Advanced techniques
  • Cric, LMA, Combitube, Retrograde, Fibreoptic,
    Light wand, Bouge

The Difficult Airway
  • Difficult Laryngoscopy
  • poor visualization of cords
  • Difficult bag-mask ventilation
  • unable to oxygenate or ventilate
  • Lower airway difficulty
  • severe bronchospasm

Golden Rules of Bagging
  • Anybody ( almost ) can be oxygenated and
    ventilated with a bag and a mask
  • The art of bagging should be mastered before the
    art of intubation
  • Manual ventilation skill with proper equipment is
    a fundamental premise of advanced airway Rx

BVM Ventilation
  • The most important airway skill
  • Always the first response to inadequate
    oxygenation and ventilation
  • The first bail-out maneuver to a failed
    intubation attempt
  • Attenuates the urgency to intubate
  • Do not abandon bagging unless it is impossible
    with two people and both an OP and NP airway

BVM Ventilation
  • Requires practice to master
  • One hand to
  • maintain face seal
  • position head
  • maintain patency
  • Other hand ventilates

BVM Ventilation Technique
  • Insert oropharyngeal/nasopharyngeal
  • Sniffingposition if C-spine OK
  • Thumb index to maintain face seal
  • Middle finger under mandibular symphysis
  • Ring/little finger under angle of mandible
  • Maintain jaw thrust/mouth open

Predictors of a Difficult Airway BVM
  • Upper airway obstruction
  • Lack of dentures
  • Beard
  • Midfacial smash
  • Facial burns, dressings, scarring
  • Poor lung mechanics
  • resistance or compliance

Difficult Airway BVM
  • degree of difficulty from zero to infinite
  • Zero no external effort or internal device
  • one person jaw thrust/ face seal
  • oropharyngeal or nasopharyngeal AW
  • two person jaw thrust / face seal
  • both internal airway devices
  • Infinite no patency despite maximal external
    effort and full use of OP/NP

Algorithm for Difficulty Bagging
  • Remove Foreign Bodies - Magill forceps
  • Triple maneuver if c-spine clear
  • Head tilt, jaw lift, mouth opening
  • Nasal or oropharyngeal airways
  • Two-person, four-hand technique

BVM Ventilation Mask Seal Tips and Pearls
  • Easier to get seals with masks too large than too
  • Inflate mask collar correctly
  • Apply lubricant to beards to mat down hair
  • If edentulous insert gauze sponges into cheeks

Prediction of the Difficult Airway Laryngoscopy
  • History of past airway problems
  • check previous OR anesthesia records if time
  • cricothyroidotomy scar
  • Careful physical assessment
  • mouth opening
  • tongue to pharyngeal size
  • hyo-mental distance
  • Neck flexion, Head extension

Technique of Laryngoscopy
  • Sniffing position to align oral-pharyngeal-laryn
    geal axis
  • Flex neck by placing pillow beneath occiput (
    raise 10 cm )
  • Extend head maximally
  • With laryngoscope
  • open mouth fully
  • push tongue to left out of view
  • pull upward at 45 degrees

Adducted vocal cords
(No Transcript)
Predictors of Difficult Laryngoscopy
  • Short thick neck
  • Receding mandible
  • Buck teeth
  • Poor mandibular mobility/ limited jaw opening
  • Limited head and neck movement
  • ( including trauma )

Difficult Airway Laryngoscopy
  • Tumor, abscess or hematoma
  • Burns
  • Angioneurotic edema
  • Blunt or penetrating trauma
  • Rheumatoid arthritis, ankylosing spondylitis
  • Congenital syndromes
  • Neck surgery or radiation

Predictors of Difficult Laryngoscopy
  • 3 fingerbreadths mentum to hyoid
  • 3 fb chin to thyroid notch
  • 3 fb upper to lower incisors
  • Head extension and neck flexion
  • Mallimpadi classification
  • Previous history of difficult intubation

Mallimpadi Classification (Tongue to
Pharyngeal Size)
  • I - soft palate, uvula, tonsillar pillars visible
  • 99 have grade I laryngoscopic view
  • II - soft palate, uvula visible
  • III - soft palate, base of uvula
  • IV - soft palate not visible
  • 100 grade III or grade IV views

The 4 Ds of Difficult Intubation
  • Distortion
  • ( edema, blood, vomitus, tumor, infection)
  • Dysmobility of joints
  • ( TMJ, alanto-occipital, C-spine)
  • Disproportion
  • thyomental, Mallimpadi, etc
  • Dentition
  • prominent upper teeth

Unsuccessful Intubation
  • Bag the patient
  • Maximize neck flex/ head ex
  • Move tongue out of line of site
  • Maximize mouth opening
  • ID landmarks and adjust blade
  • BURP maneuver (Backwards Upwards Rightwards
    Pressure on Thyroid Cart.)
  • Increasing lifting force
  • Consider Miller blade
  • Bag the patient