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Basic Emergency Airway ManagementPat Melanson,MDObjectives• 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 • LaryngoscopyEmergency Airway Management : Unique Considerations• Full stomach - high aspiration risk • Altered level of consciousness • Deteriorating cardiorespiratory physiology - (hypotension, hypoxia) • Abnormal or distorted
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Basic Emergency Airway
ManagementPat Melanson,MD
Basic Emergency Airway
ManagementPat Melanson,MD
Objectives• 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 Considerations
• 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 )
1 Patency of Upper Airway – ( airflow integrity )
2 Protection against aspiration
3 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 Patency
• Inspiratory stridor• Snoring ( pharyngeal obstruction )• Gurgling ( blood/ secretions )• Drooling ( epiglottitis )• Hoarseness ( laryngeal edema/ vocal cord
paralysis)• Paradoxical chest wall movement• Tracheal tug• Mass - abscess, hematoma, angioedema
Clinical Signs of Airway Compromise: Inadequate Protection
• 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 Compromise:Oxygenation and Ventilation
• Central cyanosis
• Obtundation and diaphoresis
• Rapid shallow respirations
• Accessory muscle use
• Retractions
• Abdominal paradox
Clinical Signs of Airway Compromise:Oxygenation 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
• “Sniffing”position 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
required• 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 small
• 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
permits– 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-laryngeal 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
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 D’s 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
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