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Case Review

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Helpful devices for intubation. that are NOT practical in the field. Light wands. Fiberoptics ... Used in surgery. Risk of aspiration. Rescue technique. Tube ... – PowerPoint PPT presentation

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Title: Case Review


1
Case Review 20THE DIFFICULT AIRWAY
  • Jim Pointer, MD, FACEP
  • Medical Director
  • Alameda County EMS

2
INTRODUCTION
  • Field intubation success rates
  • Oral 80-95
  • Nasal 60-85
  • RSI not universally available
  • Recognition of difficult airway is important
  • At least one backup, rescue airway technique is
    essential

3
DEFINITION
  • Difficult airway ANYTHING that interferes with
    ventilation or intubation
  • Anatomic
  • Traumatic
  • Infectious
  • Allergic
  • Behavioral

4
CLUES TO LOOK FOR
CL
  • Prominent incisors
  • Limited jaw / mouth opening
  • Short neck
  • Big tongue
  • Small mandible
  • Limited cervical mobility
  • Facial trauma
  • Burns
  • Neck injury
  • Obesity
  • Foreign bodies
  • Children
  • Infections
  • Allergic edema
  • Neoplasm / irradiation
  • Inhalation injuries
  • Facial hair

5
FOUR Ds
  • Distortion
  • Disproportion
  • Dysmobility
  • Dentition

6
MNEUMONIC BONES
  • Beard
  • Obese
  • No teeth
  • Elderly
  • Snoring (sleep apnea)

7
MALLAMPATI CLASSIFICATION
Class I Class II Class III Class IV
8
ANATOMY
9
60-SECOND EXAM LEMON
  • Look for external difficulty
  • Evaluate using 332 rule
  • 3 fingers fit in mouth
  • 3 fingers fit from mentum
  • to hyoid cartilage
  • 2 fingers fit from mandible
  • to top of thyroid cartilage
  • Mallampati rule (class I II)
  • Obstruction
  • Neck mobility

10
10-SECOND QUICK EXAM
  • Can you see the uvula?
  • Can you fit 3 fingers from mentum to hyoid?
  • Can the patient extend head back on neck?

11
PREPARATION
  • Prepare equipment ahead of time
  • Check and recheck
  • Gather all airway devices
  • in one bag or area
  • Pre-oxygenate with 100 O2

12
SNIFFING POSITION
  • Flex neck on chest 35
  • Extend head on neck 80
  • Use pillow or other
  • object under occiput

13
BURP, OELM, ELM
  • External
  • Laryngeal
  • Manipulation
  • Backward
  • Upward
  • Rightward
  • Pressure on thyroid cartilage
  • Optimal
  • External
  • Laryngeal
  • Manipulation

Intubator uses BURP to establish position
assistant holds in place
14
Helpful device for intubation that is practical
  • GUM ELASTIC BOUGIE (GEB)
  • Used in England
  • Cheap
  • Good in patients in whom
  • only epiglottis is visualized

15
Rotate ET tube until bevel faces posteriorly
GEB in trachea
16
Helpful devices for intubationthat are NOT
practical in the field
  • Light wands
  • Fiberoptics
  • Tracheostomy lights
  • Blind techniques

17
Adjuncts to Nasotracheal Intubation
  • Endotrol
  • Afrin and lidocaine on nasal trumpet
  • BAAM whistle
  • Positioning
  • straight back, not upward

18
Endotrol
19
BAAM Whistle
20
RESCUE AIRWAYS
21
Laryngeal Mask Airway (LMA ) and Intubating LMA
(ILMA)
  • Used in surgery
  • Risk of aspiration
  • Rescue technique
  • Tube must be used
  • with curve reversed

22
LMA and ILMA (cont.)
  • Intubating LMA
  • Accepts larger tube
  • (8.0)
  • Can be used for rescue
  • Is expensive
  • LMA ILMA not
  • used in California EMS

23
COMBITUBE
  • Most commonly used rescue airway in EMS

24
Needle or Surgical Cricothyrotomy
  • Needle must be used with high powered O2 in
    adults
  • Surgical techniques forbidden in California EMS

25
Preferred Surgical Cricothyrotomy
  • Seldinger technique
  • Catheter-over-needle
  • Wire-through-needle

26
Confirmation of Intubation Techniques
  • Auscultation
  • Both lung fields and epigastrum
  • Persistent oxygenation on pulse oximetry
  • Chest wall motion
  • Tube fogging
  • Chest x-ray
  • End-tidal CO2
  • Esophageal detector device (EDD)

27
Confirmation of Intubation Techniques (cont.)
  • ALL techniques may be unreliable!
  • End-tidal CO2 and EDD are MOST reliable.
  • Both are mandatory in Alameda County policy 10102

28
End-tidal CO2
  • Colorimetric
  • Capnography
  • Capnometry
  • Drawback
  • Cardiac arrest state

29
(No Transcript)
30
Esophageal Detector Device
  • Drawbacks
  • Air in stomach causes false positives
  • Poorer performance in obese patients
  • Cold can impact bulb type
  • MUST be used correctly

31
SUMMARY
  • Be prepared mentally logistically
  • Know how to assess a potential difficult airway
  • Use proper techniques
  • Utilize assistive devices to facilitate intubation

32
SUMMARY (cont.)
  • Know when to use rescue techniques
  • Confirm your intubation using multiple techniques
  • End-tidal CO2 and EDD are mandatory!
  • Monitor patient using pulse oximetry and
    end-tidal CO2
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