Airway Management of Patients with a Bloody Airway - PowerPoint PPT Presentation

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Airway Management of Patients with a Bloody Airway

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Airway Management of Patients with a Bloody Airway Orlando Hung Departments of Anesthesia, Surgery and Pharmacology, Dalhousie University Halifax, Nova Scotia – PowerPoint PPT presentation

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Title: Airway Management of Patients with a Bloody Airway


1
Airway Management of Patients with a Bloody Airway
  • Orlando Hung
  • Departments of Anesthesia, Surgery
  • and Pharmacology,
  • Dalhousie University
  • Halifax, Nova Scotia

2
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3
Objectives
  • Case presentation
  • Evidence based airway management
  • Strategies to secure the airway of patients with
    a bloody airway

4
Case Presentation
  • A 68 yo patient with uncontrollable epistaxis for
    2 days presents to the OR for an emergency
    exploration. He is hemodynamically stable.
  • Apart from smoking, he is otherwise healthy with
    no meds and no allergies.

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Basic Principle in Airway Management
8
Principles of Airway Management
9
Which of the following is a reasonable technique
to secure the airway?
  • Non-visual techniques (blind technique)?
  • Direct laryngoscopy using a Macintosh blade?
  • Intubation using a flexible bronchoscope?
  • Video-laryngoscopes?
  • Surgical airway?

10
Assuming that you have chosen a specific
intubation technique, how are you going to do it?
  1. Awake?
  2. Under general anesthesia?
  3. Under general anesthesia with RSI?

11
What did we do?
  • Ensure stable hemodynamics
  • Since he could not tolerate lying down flat on
    his back, dinitrogenation was achieved (PreO2) in
    a sitting position
  • Double setup with surgical AW as a backup
  • RSI using CMAC (direct vision vs video display)
    was successful

12
How did we do it?
13
Patients with blood in the oropharynx have an
increase risk of
  • Hypotension
  • Difficult intubation
  • Pulmonary aspiration
  • Hypoxemia

14
What is available in the literature to guide us
managing patients with a bloody airway?
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Post Tonsillectomy Bleed
  • Retrospective study
  • 475 pediatric patients
  • Rapid sequence induction and intubation (84),
    modified RSI (5.5), mask induction (3.2),
    through trach (0.4), unknown (6.1)
  • Most common adverse event - Hypoxemia (9.9,
    during emergence and extubation)
  • 13 patients (2.7) were difficult to intubate
    (even though initial intubations were easy) but
    all intubations were successful after 2 attempts

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18
Simulated difficult airway with bleeding
  • Prospective, randomized, crossover study
    involving 39 anesthesia practitioners
  • Manikin with immobilization of C-spine and bleed
    in the oropharynx
  • Mean intubation time
  • 47.6 sec for Glidescope
  • 21.4 sec for Macintosh
  • Adjustment maneuver(s)
  • 2.7 for Glidescope
  • 1 for Macintosh
  • Failure
  • 4 for Glidescope (took gt 120 sec)
  • 3 for Macintosh (esophageal)

19
Simulated difficult airway with bleeding
  • The investigators concluded that the Glidescope,
    used by experienced anesthesiologists in a
    simulated difficult airway, had an inferior
    performance compared to the Macintosh
    laryngoscope in terms of intubation time, number
    of intubation attempts, and number of adjustment
    maneuvers.

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Hemorrhagic airway in cadavers
  • Freshly prepared cadavers with artificial blood
    in the airway
  • 22 emergency medicine and anesthesia residents
  • Intubation time
  • CMAC 44.6 33.6 sec
  • Video blade w suction - 10.1 12.7 sec
  • Failures
  • CMAC - 6
  • Video blade w suction - none

24
Hemorrhagic airway in cadavers
  • The investigators concluded that the integrated
    video scope with suction improved intubation time
    and success compared to that of the traditional
    CMAC with Yankauer suction

25
General principles in securing an airway in
patients with blood in the oropharynx
  • Preparation treat hypovolemia, semi-sitting,
    dinitrogenation, suction(s) ready, NG?
  • May consider awake intubation, but topicalization
    can be problematic, so most would use RSI
  • Avoid blind techniques (lightwand, digital,
    intubating LMA) if at all possible
  • Intubation using a laryngoscopy under direct
    vision if at all possible
  • Laryngoscopy under indirect vision if there are
    anticipated difficulties (Rigid fiberoptic
    laryngoscopes or video llaryngoscopes)
  • Intubation using a flexible fiberoptic
    bronchoscope would be difficult

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General principles in securing an airway in
patients with blood in the oropharynx
  • Consider a surgical airway when everything fails,
    and be ready (double set-up)

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Principles of Airway Management
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Selection of a specific airway technique depends
on the clinical situation
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