Airway Management:  Part 2 EMS Professions Temple College
Risks/Protective Measures <ul><li>Be prepared for: </li></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Spitting </li...
ALS Airway/Ventilation Methods <ul><li>Gastric Tubes </li></ul><ul><ul><li>Nasogastric  </li></ul></ul><ul><ul><ul><li>Cau...
ALS Airway/Ventilation Methods <ul><li>Nasogastric Tube Insertion </li></ul><ul><ul><li>Select size (French) </li></ul></u...
ALS Airway/Ventilation Methods <ul><li>Nasogastric Tube Insertion </li></ul><ul><ul><li>Insert into nare towards angle of ...
ALS Airway/Ventilation Methods <ul><li>Orogastric Tube Insertion </li></ul><ul><ul><li>Select size (French) </li></ul></ul...
ET Introduction <ul><li>Endotracheal Intubation </li></ul><ul><ul><li>Tube into trachea to provide ventilations using BVM ...
Endotracheal Intubation <ul><li>Advantages </li></ul><ul><ul><li>Secures airway </li></ul></ul><ul><ul><li>Route for a few...
Endotracheal Intubation <ul><li>Indications </li></ul><ul><ul><li>Present or impending respiratory failure </li></ul></ul>...
Endotracheal Intubation <ul><li>These are  NOT  Indications </li></ul><ul><ul><li>Because I can intubate </li></ul></ul><u...
Endotracheal Intubation <ul><li>Complications </li></ul><ul><ul><li>Soft tissue trauma/bleeding </li></ul></ul><ul><ul><li...
Endotracheal Intubation <ul><li>Insertion Techniques </li></ul><ul><ul><li>Orotracheal Intubation (Direct Laryngoscopy) </...
Orotracheal Intubation <ul><li>Technique </li></ul><ul><ul><li>Position, ventilate patient </li></ul></ul><ul><ul><li>Moni...
ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Position patient </li></ul></ul><ul><u...
ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Elevate epiglottis </li></ul></ul><ul>...
ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Advance tube into glottic opening abou...
ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Secure tube </li></ul></ul><ul><ul><li...
Intubation Total time between ventilations should not exceed 30 seconds!
Intubation <ul><li>Death occurs from  failure to Ventilate ,  </li></ul><ul><li>not failure to Intubate </li></ul>
ALS Equipment <ul><li>Equipment </li></ul><ul><ul><li>Laryngoscope Handle (lighted) & Blades </li></ul></ul><ul><ul><li>St...
ALS Equipment
ALS Equipment From AHA PALS
ALS Equipment
Pediatric ET Intubation <ul><li>Pediatric Equipment Differences </li></ul><ul><ul><li>Uncuffed tube < 8 yoa </li></ul></ul...
Positioning <ul><li>Patient Positioning </li></ul><ul><ul><li>Goal </li></ul></ul><ul><ul><ul><li>Align 3 planes of view, ...
 
Airway Assessment <ul><li>Cervical Spine </li></ul><ul><li>Temporal Mandibular Joint </li></ul><ul><li>A/O Joint </li></ul...
Assessment Acronym <ul><li>M  Mandible </li></ul><ul><li>O  Opening </li></ul><ul><li>U  Uvula </li></ul><ul><li>T  Teeth ...
The Lemon Law <ul><li>L Look externally </li></ul><ul><li>E Evaluate the 3-3-2 rule </li></ul><ul><li>M Mallampati score <...
Look  <ul><li>Morbidly obese </li></ul><ul><li>Facial hair </li></ul><ul><li>Narrow face </li></ul><ul><li>Overbite </li><...
Evaluate  3 - 3 - 2 <ul><li>Temporal Mandibular Joint </li></ul><ul><ul><li>Should allow 3 fingers between incisors </li><...
Evaluate  3 - 3 - 2 <ul><li>Mandible </li></ul><ul><ul><li>3 fingers between mentum & hyoid bone </li></ul></ul><ul><ul><l...
Evaluate  3 - 3 - 2 <ul><li>Larynx </li></ul><ul><ul><li>Adult located C5,6 </li></ul></ul><ul><ul><li>If higher, obstruct...
Mallampati Score <ul><li>Evaluates ability to visualize glottic opening </li></ul><ul><ul><li>Patient seated with neck ext...
Mallampati Score <ul><li>Not useful in emergent situations </li></ul><ul><li>Informal version </li></ul><ul><ul><li>Use to...
 
Mallampati Grades    Difficulty    Class I   Class II   Class III   Class IV
Obstruction <ul><li>Know or suspected </li></ul><ul><ul><li>Foreign bodies </li></ul></ul><ul><ul><li>Tumors </li></ul></u...
Neck Mobility <ul><li>Align axis to facilitate orotracheal intubation </li></ul><ul><li>Decreased mobility from </li></ul>...
Curved Blade (Macintosh) <ul><li>Insert from right to left </li></ul><ul><li>Visualize anatomy  </li></ul><ul><li>Blade in...
Straight Blade (Miller) <ul><li>Insert from right to left </li></ul><ul><li>Visualize anatomy </li></ul><ul><li>Blade past...
Glottic Opening <ul><li>Cormack-Lehane laryngoscopy grading system  </li></ul><ul><li>Grade 1 & 2 low failure rates </li><...
Tube Placement From TRIPP, CPEM
Confirmation of Placement
<ul><li>Placement of the ETT within the esophagus is an accepted complication. </li></ul><ul><li>However, failure to recog...
Traditional Methods <ul><li>Observation of ETT passing through vocal cords. </li></ul><ul><li>Presence of breath sounds </...
<ul><li>All of these methods  have  failed in the clinical setting </li></ul>
Additional Methods <ul><li>Pulse Oximetry </li></ul><ul><li>Aspiration Techniques </li></ul><ul><li>End Tidal CO 2 </li></ul>
Confirming ETT Location  <ul><li>Fail Safe </li></ul><ul><li>Near Fail Safe </li></ul><ul><li>Non-Fail Safe </li></ul>
Fail Safe <ul><li>Improvement in Clinical Signs </li></ul><ul><li>ETT visualized between vocal cords </li></ul><ul><li>Fib...
Near Failsafe <ul><li>CO2 detection </li></ul><ul><li>Rapid inflation of EDD </li></ul>
Non-Failsafe <ul><li>Presence of breath sounds </li></ul><ul><li>Absence of epigastric sounds </li></ul><ul><li>Absence of...
Non Failsafe <ul><li>Condensation in tube disappearing and reappearing with respiration </li></ul><ul><li>Air exiting tube...
ALS Airway/Ventilation Methods <ul><li>Blind Nasotracheal Intubation </li></ul><ul><ul><li>Position, oxygenate patient </l...
ALS Airway/Ventilation Methods <ul><li>Blind Nasotracheal Intubation </li></ul><ul><ul><li>Assess for difficulty or contra...
ALS Airway/Ventilation Methods <ul><li>Blind Nasotracheal Intubation </li></ul><ul><ul><li>Position patient (preferably si...
ALS Airway/Ventilation Methods <ul><li>Digital Intubation </li></ul><ul><ul><li>Blind technique  </li></ul></ul><ul><ul><l...
ALS Airway/Ventilation Methods Digital Intubation From AMLS, NAEMT
ALS Airway Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><u...
ALS Airway/Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Contraindications (relative) </li></u...
ALS Airway/Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Tips </li></ul></ul><ul><ul><ul><li>K...
ALS Airway/Ventilation Methods <ul><li>Needle Cricothyrotomy/Transtracheal Jet Ventilation </li></ul><ul><ul><li>Indicatio...
ALS Airway/Ventilation Methods <ul><li>Jet Ventilation </li></ul><ul><ul><li>Usually requires high-pressure equipment </li...
ALS Airway/ Ventilation Methods <ul><li>Alternative Airways </li></ul><ul><ul><li>Multi-Lumen Devices (CombiTube, PTLA) </...
ALS Airway/ Ventilation Methods Pharyngeal Tracheal Lumen Airway (PTLA)  From AMLS, NAEMT
ALS Airway/ Ventilation Methods Combitube® From AMLS, NAEMT
ALS Airway/ Ventilation Methods <ul><li>Combitube ® </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Contraind...
ALS Airway/ Ventilation Methods <ul><li>Laryngeal Mask Airway (LMA) </li></ul><ul><ul><li>   use in OR </li></ul></ul><ul...
LMA
ALS Airway/ Ventilation Methods
BLS & ALS Airway/ Ventilation Methods <ul><li>Esophageal Obturator Airway, Esophageal Gastric Tube Airway </li></ul><ul><u...
Esophageal Gastric Tube Airway (EGTA) From AHA ACLS
ALS Airway/ Ventilation Methods <ul><li>Lighted Stylette </li></ul><ul><ul><li>Not yet widely used </li></ul></ul><ul><ul>...
Lighted Slyest
ALS Airway/Ventilation Methods
Pharmacologic Assisted Intubation “RSI” <ul><li>Sedation </li></ul><ul><ul><li>Reduce anxiety </li></ul></ul><ul><ul><li>I...
Pharmacologic Assisted Intubation “RSI” <ul><li>Common Medications for Sedation </li></ul><ul><ul><li>Benzodiazepines (dia...
Pharmacologic Assisted Intubation <ul><li>Neuromuscular Blockade  </li></ul><ul><ul><li>Temporary skeletal muscle paralysi...
Pharmacologic Assisted Intubation <ul><li>Neuromuscular Blockade  </li></ul><ul><ul><li>Contraindications </li></ul></ul><...
Pharmacologic Assisted Intubation <ul><li>NMB Agent Mechanism of Action </li></ul><ul><ul><li>Acts at neuromuscular juncti...
Pharmacologic Assisted Intubation <ul><li>Disadvantages/Potential Complications </li></ul><ul><ul><li>Does not provide sed...
Pharmacologic Assisted Intubation <ul><li>Common Used NMB Agents </li></ul><ul><ul><li>Depolarizing NMB agents </li></ul><...
Pharmacologic Assisted Intubation <ul><ul><li>Summarized Procedure </li></ul></ul><ul><ul><ul><li>Prepare all equipment, m...
Pharmacologic Assisted Intubation <ul><li>Failure is not an option! </li></ul>
ALS Airway/Ventilation Methods <ul><li>Needle Thoracostomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><l...
ALS Airway/Ventilation Methods <ul><li>Tension Pneumothorax Signs/Symptoms </li></ul><ul><ul><li>Severe respiratory distre...
ALS Airway/Ventilation Methods <ul><li>Needle Thoracostomy </li></ul><ul><ul><li>Prepare equipment </li></ul></ul><ul><ul>...
ALS Airway/Ventilation Methods <ul><li>Chest Escharotomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>...
ALS Airway/Ventilation Methods <ul><li>Chest Escharotomy </li></ul><ul><ul><li>Procedure </li></ul></ul><ul><ul><ul><li>In...
Airway & Ventilation Methods <ul><li>Saturday’s class </li></ul><ul><ul><li>Practice using equipment </li></ul></ul><ul><u...
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Airway Management 2

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  • Mouths Can J Anaesth 1991; 38:687 Davies, Eagle M Length of Mandible, subluxation to mandible. Is the mandibular space wide enough O Ease, symerty and range of opening U Mallampati score T adequate dentation, loose teeth, dental appliances H flexion, extension, rotation of head upon neck S Obesity, buffalo hump, kyphosis. Large breast
  • Makes intubation and ventilation difficult or impossible even in the absence of other predictions Blood vomitus fluid edema
  • Airway Management 2

    1. 1. Airway Management: Part 2 EMS Professions Temple College
    2. 2. Risks/Protective Measures <ul><li>Be prepared for: </li></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Spitting </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Biting </li></ul></ul><ul><li>Body Substance Isolation </li></ul><ul><ul><li>Gloves </li></ul></ul><ul><ul><li>Face, eye shields </li></ul></ul><ul><ul><li>Respirator, if concern for airborne disease </li></ul></ul>
    3. 3. ALS Airway/Ventilation Methods <ul><li>Gastric Tubes </li></ul><ul><ul><li>Nasogastric </li></ul></ul><ul><ul><ul><li>Caution with esophageal disease or facial trauma </li></ul></ul></ul><ul><ul><ul><li>Tolerated by awake patients, but uncomfortable </li></ul></ul></ul><ul><ul><ul><li>Patient can speak </li></ul></ul></ul><ul><ul><ul><li>Interferes with BVM seal </li></ul></ul></ul><ul><ul><li>Orogastric </li></ul></ul><ul><ul><ul><li>Usually used in unresponsive patients </li></ul></ul></ul><ul><ul><ul><li>Larger tube may be used </li></ul></ul></ul><ul><ul><ul><li>Safe in facial trauma </li></ul></ul></ul>
    4. 4. ALS Airway/Ventilation Methods <ul><li>Nasogastric Tube Insertion </li></ul><ul><ul><li>Select size (French) </li></ul></ul><ul><ul><li>Measure length (nose to ear to xiphoid) </li></ul></ul><ul><ul><li>Lubricate end of tube (water soluble) </li></ul></ul><ul><ul><li>Maintain aseptic technique </li></ul></ul><ul><ul><li>Position patient sitting up if possible </li></ul></ul>
    5. 5. ALS Airway/Ventilation Methods <ul><li>Nasogastric Tube Insertion </li></ul><ul><ul><li>Insert into nare towards angle of jaw </li></ul></ul><ul><ul><li>Advance gradually to measured length </li></ul></ul><ul><ul><li>Have patient swallow </li></ul></ul><ul><ul><li>Assess placement </li></ul></ul><ul><ul><ul><li>Instill air, ausculate </li></ul></ul></ul><ul><ul><ul><li>aspirate gastric contents </li></ul></ul></ul><ul><ul><li>Secure </li></ul></ul><ul><ul><li>May connect to low vacuum (80-100 mm Hg) </li></ul></ul>
    6. 6. ALS Airway/Ventilation Methods <ul><li>Orogastric Tube Insertion </li></ul><ul><ul><li>Select size (French) </li></ul></ul><ul><ul><li>Measure length </li></ul></ul><ul><ul><li>Lubricate end of tube </li></ul></ul><ul><ul><li>Position patient (usually supine) </li></ul></ul><ul><ul><li>Insert into mouth </li></ul></ul><ul><ul><li>Advance gradually but steadily </li></ul></ul><ul><ul><li>Assess placement (instill air or aspirate) </li></ul></ul><ul><ul><li>Secure </li></ul></ul><ul><ul><li>Evacuate contents as needed </li></ul></ul>
    7. 7. ET Introduction <ul><li>Endotracheal Intubation </li></ul><ul><ul><li>Tube into trachea to provide ventilations using BVM or ventilator </li></ul></ul><ul><ul><li>Sized based upon inside diameter (ID) in mm </li></ul></ul><ul><ul><li>Lengths increase with increased ID (cm markings along length) </li></ul></ul><ul><ul><li>Cuffed vs. Uncuffed </li></ul></ul>
    8. 8. Endotracheal Intubation <ul><li>Advantages </li></ul><ul><ul><li>Secures airway </li></ul></ul><ul><ul><li>Route for a few medications (LANE) </li></ul></ul><ul><ul><li>Optimizes ventilation, oxygenation </li></ul></ul><ul><ul><li>Allows suctioning of lower airway </li></ul></ul>
    9. 9. Endotracheal Intubation <ul><li>Indications </li></ul><ul><ul><li>Present or impending respiratory failure </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Unable to protect own airway </li></ul></ul>
    10. 10. Endotracheal Intubation <ul><li>These are NOT Indications </li></ul><ul><ul><li>Because I can intubate </li></ul></ul><ul><ul><li>Because they are unresponsive </li></ul></ul><ul><ul><li>Because I can’t show up at the hospital without it </li></ul></ul>
    11. 11. Endotracheal Intubation <ul><li>Complications </li></ul><ul><ul><li>Soft tissue trauma/bleeding </li></ul></ul><ul><ul><li>Dental injury </li></ul></ul><ul><ul><li>Laryngeal edema </li></ul></ul><ul><ul><li>Laryngospasm </li></ul></ul><ul><ul><li>Vocal cord injury </li></ul></ul><ul><ul><li>Barotrauma </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>Esophageal intubation </li></ul></ul><ul><ul><li>Mainstem bronchus intubation </li></ul></ul>
    12. 12. Endotracheal Intubation <ul><li>Insertion Techniques </li></ul><ul><ul><li>Orotracheal Intubation (Direct Laryngoscopy) </li></ul></ul><ul><ul><li>Blind Nasotracheal Intubation </li></ul></ul><ul><ul><li>Digital Intubation </li></ul></ul><ul><ul><li>Retrograde Intubation </li></ul></ul><ul><ul><li>Transillumination </li></ul></ul>
    13. 13. Orotracheal Intubation <ul><li>Technique </li></ul><ul><ul><li>Position, ventilate patient </li></ul></ul><ul><ul><li>Monitor patient </li></ul></ul><ul><ul><ul><li>ECG </li></ul></ul></ul><ul><ul><ul><li>Pulse oximeter </li></ul></ul></ul><ul><ul><li>Assess patient’s airway for difficulty </li></ul></ul><ul><ul><li>Assemble, check equipment (suction) </li></ul></ul><ul><ul><li>Hyperventilate patient (30-120 sec) </li></ul></ul>
    14. 14. ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Position patient </li></ul></ul><ul><ul><li>Open mouth </li></ul></ul><ul><ul><li>Insert laryngoscope blade on right side </li></ul></ul><ul><ul><li>Sweep tongue to left </li></ul></ul><ul><ul><li>Identify anatomical landmarks </li></ul></ul><ul><ul><li>Advance laryngoscope blade </li></ul></ul><ul><ul><ul><li>Vallecula for curved (Miller) blade </li></ul></ul></ul><ul><ul><ul><li>Under epiglottis for straight (Miller) blade </li></ul></ul></ul>
    15. 15. ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Elevate epiglottis </li></ul></ul><ul><ul><li>Directly with straight (Miller) blade </li></ul></ul><ul><ul><li>Indirectly with curved (Macintosh) blade </li></ul></ul><ul><ul><li>Visualize vocal cords, glottic opening </li></ul></ul><ul><ul><li>Enter mouth with tube from corner of mouth </li></ul></ul>
    16. 16. ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Advance tube into glottic opening about 1/2 inch past vocal cords </li></ul></ul><ul><ul><li>Continue to hold tube, note location </li></ul></ul><ul><ul><li>Ventilate, ausculate </li></ul></ul><ul><ul><ul><li>Epigastrium </li></ul></ul></ul><ul><ul><ul><li>Left and right chest </li></ul></ul></ul><ul><ul><li>Inflate cuff until air leak around cuff stops </li></ul></ul><ul><ul><li>Reassess tube placement </li></ul></ul>
    17. 17. ALS Airway/Ventilation Methods <ul><li>Orotracheal Intubation </li></ul><ul><ul><li>Secure tube </li></ul></ul><ul><ul><li>Reassess tube placement, ventilation effectiveness </li></ul></ul>
    18. 18. Intubation Total time between ventilations should not exceed 30 seconds!
    19. 19. Intubation <ul><li>Death occurs from failure to Ventilate , </li></ul><ul><li>not failure to Intubate </li></ul>
    20. 20. ALS Equipment <ul><li>Equipment </li></ul><ul><ul><li>Laryngoscope Handle (lighted) & Blades </li></ul></ul><ul><ul><li>Stylet </li></ul></ul><ul><ul><li>Syringe </li></ul></ul><ul><ul><li>Magills </li></ul></ul><ul><ul><li>Lubricant </li></ul></ul><ul><ul><li>Suction </li></ul></ul><ul><ul><li>BVM </li></ul></ul><ul><ul><li>BAAM (Blind Nasal) </li></ul></ul><ul><li>Selection </li></ul><ul><ul><li>Typical Adult ET Tube Sizes </li></ul></ul><ul><ul><ul><li>Male - 8.0, 8.5 </li></ul></ul></ul><ul><ul><ul><li>Female - 7.0, 7.5, 8.0 </li></ul></ul></ul><ul><ul><li>Blade </li></ul></ul><ul><ul><ul><li>Mac - 3 or 4 </li></ul></ul></ul><ul><ul><ul><li>Miller - 3 </li></ul></ul></ul><ul><ul><li>Tube Depth </li></ul></ul><ul><ul><ul><li>Usually 20 - 22 cm at the teeth </li></ul></ul></ul>
    21. 21. ALS Equipment
    22. 22. ALS Equipment From AHA PALS
    23. 23. ALS Equipment
    24. 24. Pediatric ET Intubation <ul><li>Pediatric Equipment Differences </li></ul><ul><ul><li>Uncuffed tube < 8 yoa </li></ul></ul><ul><ul><li>Miller blade preferred </li></ul></ul><ul><ul><li>Tube Size </li></ul></ul><ul><ul><ul><li>Premie: 2.0, 2.5 </li></ul></ul></ul><ul><ul><ul><li>Newborn: 3.0, 3.5 </li></ul></ul></ul><ul><ul><ul><li>1 year: 4 </li></ul></ul></ul><ul><ul><ul><li>Then: (age/4)+4 </li></ul></ul></ul><ul><li>Pediatric Differences </li></ul><ul><ul><li>Anatomic Differences </li></ul></ul><ul><ul><li>Depth (cm) </li></ul></ul><ul><ul><ul><li>Tube ID x 3 </li></ul></ul></ul><ul><ul><ul><li>12 + (age/2) </li></ul></ul></ul><ul><ul><ul><li>easily dislodged </li></ul></ul></ul><ul><ul><li>Intubation vs BVM </li></ul></ul>
    25. 25. Positioning <ul><li>Patient Positioning </li></ul><ul><ul><li>Goal </li></ul></ul><ul><ul><ul><li>Align 3 planes of view, so </li></ul></ul></ul><ul><ul><ul><li>Vocal cords are most visible </li></ul></ul></ul><ul><ul><li>T - trachea </li></ul></ul><ul><ul><li>P - Pharynx </li></ul></ul><ul><ul><li>O - Oropharynx </li></ul></ul>
    26. 27. Airway Assessment <ul><li>Cervical Spine </li></ul><ul><li>Temporal Mandibular Joint </li></ul><ul><li>A/O Joint </li></ul><ul><li>Neck length, size and muscularity </li></ul><ul><li>Mandibular size in relation to face </li></ul><ul><li>Over bite </li></ul><ul><li>Tongue size </li></ul>
    27. 28. Assessment Acronym <ul><li>M Mandible </li></ul><ul><li>O Opening </li></ul><ul><li>U Uvula </li></ul><ul><li>T Teeth </li></ul><ul><li>H Head </li></ul><ul><li>S Silhouette </li></ul>
    28. 29. The Lemon Law <ul><li>L Look externally </li></ul><ul><li>E Evaluate the 3-3-2 rule </li></ul><ul><li>M Mallampati score </li></ul><ul><li>O Obstruction? </li></ul><ul><li>N Neck Mobility </li></ul>
    29. 30. Look <ul><li>Morbidly obese </li></ul><ul><li>Facial hair </li></ul><ul><li>Narrow face </li></ul><ul><li>Overbite </li></ul><ul><li>Trauma </li></ul>
    30. 31. Evaluate 3 - 3 - 2 <ul><li>Temporal Mandibular Joint </li></ul><ul><ul><li>Should allow 3 fingers between incisors </li></ul></ul><ul><ul><li>3-4 cm </li></ul></ul>
    31. 32. Evaluate 3 - 3 - 2 <ul><li>Mandible </li></ul><ul><ul><li>3 fingers between mentum & hyoid bone </li></ul></ul><ul><ul><li>Less than three fingers </li></ul></ul><ul><ul><ul><li>Proportionately large tongue </li></ul></ul></ul><ul><ul><ul><li>Obstructs visualization of glottic opening </li></ul></ul></ul><ul><ul><li>Greater than three fingers </li></ul></ul><ul><ul><ul><li>Elongates oral axis </li></ul></ul></ul><ul><ul><ul><li>More difficult to align the three axis </li></ul></ul></ul>
    32. 33. Evaluate 3 - 3 - 2 <ul><li>Larynx </li></ul><ul><ul><li>Adult located C5,6 </li></ul></ul><ul><ul><li>If higher, obstructive view of glottic opening </li></ul></ul><ul><ul><li>Two fingers from floor of mouth to thyroid cartilage </li></ul></ul>
    33. 34. Mallampati Score <ul><li>Evaluates ability to visualize glottic opening </li></ul><ul><ul><li>Patient seated with neck extended </li></ul></ul><ul><ul><li>Open mouth as wide as possible </li></ul></ul><ul><ul><li>Protrude tongue as far as possible </li></ul></ul><ul><ul><li>Look at posterior pharynx </li></ul></ul><ul><ul><li>Grade based on visual field </li></ul></ul><ul><ul><ul><li>Grades 1,2 have low intubation failure rates </li></ul></ul></ul><ul><ul><ul><li>Grades 3,4 have higher intubation failure rates </li></ul></ul></ul>
    34. 35. Mallampati Score <ul><li>Not useful in emergent situations </li></ul><ul><li>Informal version </li></ul><ul><ul><li>Use tongue blade to visualize pharynx </li></ul></ul>
    35. 37. Mallampati Grades  Difficulty  Class I Class II Class III Class IV
    36. 38. Obstruction <ul><li>Know or suspected </li></ul><ul><ul><li>Foreign bodies </li></ul></ul><ul><ul><li>Tumors </li></ul></ul><ul><ul><li>Abscess </li></ul></ul><ul><ul><li>Epiglottitis </li></ul></ul><ul><ul><li>Hematoma </li></ul></ul><ul><ul><li>Trauma </li></ul></ul>
    37. 39. Neck Mobility <ul><li>Align axis to facilitate orotracheal intubation </li></ul><ul><li>Decreased mobility from </li></ul><ul><ul><li>C-Spine immobilization </li></ul></ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul><ul><li>Quick Test </li></ul><ul><ul><li>Put chin on chest then move toward ceiling </li></ul></ul>
    38. 40. Curved Blade (Macintosh) <ul><li>Insert from right to left </li></ul><ul><li>Visualize anatomy </li></ul><ul><li>Blade in vallecula </li></ul><ul><li>Lift up and away DO NOT PRY ON TEETH </li></ul><ul><li>Lift epiglottis indirectly </li></ul>From AHA ACLS
    39. 41. Straight Blade (Miller) <ul><li>Insert from right to left </li></ul><ul><li>Visualize anatomy </li></ul><ul><li>Blade past vallecula and over epiglottis </li></ul><ul><li>Lift up and away DO NOT PRY ON TEETH </li></ul><ul><li>Lift epiglottis directly </li></ul>From AHA ACLS
    40. 42. Glottic Opening <ul><li>Cormack-Lehane laryngoscopy grading system </li></ul><ul><li>Grade 1 & 2 low failure rates </li></ul><ul><li>Grade 3 & 4 high failure rates </li></ul>
    41. 43. Tube Placement From TRIPP, CPEM
    42. 44. Confirmation of Placement
    43. 45. <ul><li>Placement of the ETT within the esophagus is an accepted complication. </li></ul><ul><li>However, failure to recognize and correct is not! </li></ul>
    44. 46. Traditional Methods <ul><li>Observation of ETT passing through vocal cords. </li></ul><ul><li>Presence of breath sounds </li></ul><ul><li>Absence of epigastric sounds </li></ul><ul><li>Symmetric rise and fall of chest </li></ul><ul><li>Condensation in ETT </li></ul><ul><li>Chest Radiograph </li></ul>
    45. 47. <ul><li>All of these methods have failed in the clinical setting </li></ul>
    46. 48. Additional Methods <ul><li>Pulse Oximetry </li></ul><ul><li>Aspiration Techniques </li></ul><ul><li>End Tidal CO 2 </li></ul>
    47. 49. Confirming ETT Location <ul><li>Fail Safe </li></ul><ul><li>Near Fail Safe </li></ul><ul><li>Non-Fail Safe </li></ul>
    48. 50. Fail Safe <ul><li>Improvement in Clinical Signs </li></ul><ul><li>ETT visualized between vocal cords </li></ul><ul><li>Fiberoptic visualization of </li></ul><ul><ul><li>Cartilaginous rings </li></ul></ul><ul><ul><li>Carina </li></ul></ul>
    49. 51. Near Failsafe <ul><li>CO2 detection </li></ul><ul><li>Rapid inflation of EDD </li></ul>
    50. 52. Non-Failsafe <ul><li>Presence of breath sounds </li></ul><ul><li>Absence of epigastric sounds </li></ul><ul><li>Absence of gastric distention </li></ul><ul><li>Chest Rise and Fall </li></ul><ul><li>Large Spontaneous Exhaled Tidal Volumes </li></ul>
    51. 53. Non Failsafe <ul><li>Condensation in tube disappearing and reappearing with respiration </li></ul><ul><li>Air exiting tube with chest compression </li></ul><ul><li>Bag Valve Mask having the appropriate compliance </li></ul><ul><li>Pressure on suprasternal notch associated with pilot balloon pressure </li></ul>
    52. 54. ALS Airway/Ventilation Methods <ul><li>Blind Nasotracheal Intubation </li></ul><ul><ul><li>Position, oxygenate patient </li></ul></ul><ul><ul><li>Monitor patient </li></ul></ul><ul><ul><ul><li>ECG monitor </li></ul></ul></ul><ul><ul><ul><li>Pulse oximeter </li></ul></ul></ul>
    53. 55. ALS Airway/Ventilation Methods <ul><li>Blind Nasotracheal Intubation </li></ul><ul><ul><li>Assess for difficulty or contraindication </li></ul></ul><ul><ul><ul><li>Mid-face fractures </li></ul></ul></ul><ul><ul><ul><li>Possible basilar skull fracture </li></ul></ul></ul><ul><ul><ul><li>Evidence of nasal obstruction, septal deviation </li></ul></ul></ul><ul><ul><li>Assemble, check equipment </li></ul></ul><ul><ul><ul><li>Lubricate end of tube; do not warm </li></ul></ul></ul><ul><ul><ul><li>Attach BAAM (if available) </li></ul></ul></ul>
    54. 56. ALS Airway/Ventilation Methods <ul><li>Blind Nasotracheal Intubation </li></ul><ul><ul><li>Position patient (preferably sitting upright) </li></ul></ul><ul><ul><li>Insert tube into largest nare </li></ul></ul><ul><ul><li>Advance slowly, but steadily </li></ul></ul><ul><ul><li>Listen for sound of air movement in tube or whistle via BAAM </li></ul></ul><ul><ul><li>Advance tube </li></ul></ul><ul><ul><li>Assess placement </li></ul></ul><ul><ul><li>Inflate cuff, reassess placement </li></ul></ul><ul><ul><li>Secure, reassess placement </li></ul></ul>
    55. 57. ALS Airway/Ventilation Methods <ul><li>Digital Intubation </li></ul><ul><ul><li>Blind technique </li></ul></ul><ul><ul><li>Variable probability of success </li></ul></ul><ul><ul><li>Using middle finger to locate epiglottis </li></ul></ul><ul><ul><li>Lift epiglottis </li></ul></ul><ul><ul><li>Slide lubricated tube along index finger </li></ul></ul><ul><ul><li>Assess tube placement/depth as with orotracheal intubation </li></ul></ul>
    56. 58. ALS Airway/Ventilation Methods Digital Intubation From AMLS, NAEMT
    57. 59. ALS Airway Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Absolute need for definitive airway, AND </li></ul></ul></ul><ul><ul><ul><ul><li>unable to perform ETT due for structural or anatomic reasons, AND </li></ul></ul></ul></ul><ul><ul><ul><ul><li>risk of not securing airway is > than surgical airway risk </li></ul></ul></ul></ul><ul><ul><ul><li>OR </li></ul></ul></ul><ul><ul><ul><li>Absolute need for definitive airway AND </li></ul></ul></ul><ul><ul><ul><ul><li>unable to clear an upper airway obstruction, AND </li></ul></ul></ul></ul><ul><ul><ul><ul><li>multiple unsuccessful attempts at ETT, AND </li></ul></ul></ul></ul><ul><ul><ul><ul><li>other methods of ventilation do not allow for effective ventilation, respiration </li></ul></ul></ul></ul>
    58. 60. ALS Airway/Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Contraindications (relative) </li></ul></ul><ul><ul><ul><li>No real demonstrated indication </li></ul></ul></ul><ul><ul><ul><li>Risks > Benefits </li></ul></ul></ul><ul><ul><ul><li>Age < 8 years (some say 10, some say 12) </li></ul></ul></ul><ul><ul><ul><li>Evidence of fractured larynx or cricoid cartilage </li></ul></ul></ul><ul><ul><ul><li>Evidence of tracheal transection </li></ul></ul></ul>
    59. 61. ALS Airway/Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Tips </li></ul></ul><ul><ul><ul><li>Know anatomy </li></ul></ul></ul><ul><ul><ul><li>Short incision, avoid inferior trachea </li></ul></ul></ul><ul><ul><ul><li>Incise, do not saw </li></ul></ul></ul><ul><ul><ul><li>Work quickly </li></ul></ul></ul><ul><ul><ul><li>Nothing comes out until something else is in </li></ul></ul></ul><ul><ul><ul><li>Have a plan </li></ul></ul></ul><ul><ul><ul><li>Be prepared with backup plan </li></ul></ul></ul>
    60. 62. ALS Airway/Ventilation Methods <ul><li>Needle Cricothyrotomy/Transtracheal Jet Ventilation </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Same as surgical cricothyrotomy with </li></ul></ul></ul><ul><ul><ul><li>Contraindication for surgical cricothyrotomy </li></ul></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>None when demonstrated need </li></ul></ul></ul><ul><ul><ul><li>Caution with tracheal transection </li></ul></ul></ul>
    61. 63. ALS Airway/Ventilation Methods <ul><li>Jet Ventilation </li></ul><ul><ul><li>Usually requires high-pressure equipment </li></ul></ul><ul><ul><li>Ventilate 1 sec then allow 3-5 sec pause </li></ul></ul><ul><ul><li>Hypercarbia likely </li></ul></ul><ul><ul><li>Temporary : 20-30 mins </li></ul></ul><ul><ul><li>High risk for barotrauma </li></ul></ul>
    62. 64. ALS Airway/ Ventilation Methods <ul><li>Alternative Airways </li></ul><ul><ul><li>Multi-Lumen Devices (CombiTube, PTLA) </li></ul></ul><ul><ul><li>Laryngeal Mask Airway (LMA) </li></ul></ul><ul><ul><li>Esophageal Obturator Airways (EOA, EGTA) </li></ul></ul><ul><ul><li>Lighted Stylets </li></ul></ul>
    63. 65. ALS Airway/ Ventilation Methods Pharyngeal Tracheal Lumen Airway (PTLA) From AMLS, NAEMT
    64. 66. ALS Airway/ Ventilation Methods Combitube® From AMLS, NAEMT
    65. 67. ALS Airway/ Ventilation Methods <ul><li>Combitube ® </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>Height </li></ul></ul></ul><ul><ul><ul><li>Gag reflex </li></ul></ul></ul><ul><ul><ul><li>Ingestion of corrosive or volatile substances </li></ul></ul></ul><ul><ul><ul><li>Hx of esophageal disease </li></ul></ul></ul>
    66. 68. ALS Airway/ Ventilation Methods <ul><li>Laryngeal Mask Airway (LMA) </li></ul><ul><ul><li> use in OR </li></ul></ul><ul><ul><li>Gaining use out-of-hospital </li></ul></ul><ul><ul><li>Not useful with high airway pressure </li></ul></ul><ul><ul><li>Not replacement for endotracheal tube </li></ul></ul><ul><ul><li>Multiple models, sizes </li></ul></ul>
    67. 69. LMA
    68. 70. ALS Airway/ Ventilation Methods
    69. 71. BLS & ALS Airway/ Ventilation Methods <ul><li>Esophageal Obturator Airway, Esophageal Gastric Tube Airway </li></ul><ul><ul><li>Used less frequently today </li></ul></ul><ul><ul><li>Increased complication rate </li></ul></ul><ul><ul><li>Significant contraindications </li></ul></ul><ul><ul><ul><li>Patient height </li></ul></ul></ul><ul><ul><ul><li>Caustic ingestion </li></ul></ul></ul><ul><ul><ul><li>Esophageal/liver disease </li></ul></ul></ul><ul><ul><li>Better alternative airways are now available </li></ul></ul>
    70. 72. Esophageal Gastric Tube Airway (EGTA) From AHA ACLS
    71. 73. ALS Airway/ Ventilation Methods <ul><li>Lighted Stylette </li></ul><ul><ul><li>Not yet widely used </li></ul></ul><ul><ul><li>Expensive </li></ul></ul><ul><ul><li>Another method of visual feedback about placement in trachea </li></ul></ul>
    72. 74. Lighted Slyest
    73. 75. ALS Airway/Ventilation Methods
    74. 76. Pharmacologic Assisted Intubation “RSI” <ul><li>Sedation </li></ul><ul><ul><li>Reduce anxiety </li></ul></ul><ul><ul><li>Induce amnesia </li></ul></ul><ul><ul><li>Depress gag reflex, spontaneous breathing </li></ul></ul><ul><ul><li>Used for </li></ul></ul><ul><ul><ul><li>induction </li></ul></ul></ul><ul><ul><ul><li>anxious, agitated patient </li></ul></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>hypersensitivity </li></ul></ul></ul><ul><ul><ul><li>hypotension </li></ul></ul></ul>
    75. 77. Pharmacologic Assisted Intubation “RSI” <ul><li>Common Medications for Sedation </li></ul><ul><ul><li>Benzodiazepines (diazepam, midazolam) </li></ul></ul><ul><ul><li>Narcotics (fentanyl) </li></ul></ul><ul><ul><li>Anesthesia Induction Agents </li></ul></ul><ul><ul><ul><li>Etomidate </li></ul></ul></ul><ul><ul><ul><li>Ketamine </li></ul></ul></ul><ul><ul><ul><li>Propofol (Diprivan®) </li></ul></ul></ul>
    76. 78. Pharmacologic Assisted Intubation <ul><li>Neuromuscular Blockade </li></ul><ul><ul><li>Temporary skeletal muscle paralysis </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>When intubation required in patient who: </li></ul></ul></ul><ul><ul><ul><ul><li>is awake, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>has gag reflex, or </li></ul></ul></ul></ul><ul><ul><ul><ul><li>is agitated, combative </li></ul></ul></ul></ul>
    77. 79. Pharmacologic Assisted Intubation <ul><li>Neuromuscular Blockade </li></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>Most are specific to medication </li></ul></ul></ul><ul><ul><ul><li>Inability to ventilate once paralysis induced </li></ul></ul></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>Enables provider to intubate patients who otherwise would be difficult, impossible to intubate </li></ul></ul></ul><ul><ul><ul><li>Minimizes patient resistance to intubation </li></ul></ul></ul><ul><ul><ul><li>Reduces risk of laryngospasm </li></ul></ul></ul>
    78. 80. Pharmacologic Assisted Intubation <ul><li>NMB Agent Mechanism of Action </li></ul><ul><ul><li>Acts at neuromuscular junction where ACh normally allows nerve impulse transmission </li></ul></ul><ul><ul><li>Binds to nicotinic receptor sites on skeletal muscle </li></ul></ul><ul><ul><li>Depolarizing or non-depolarizing </li></ul></ul><ul><ul><li>Blocks further action by ACh at receptor sites </li></ul></ul><ul><ul><li>Blocks further depolarization resulting in muscular paralysis </li></ul></ul>
    79. 81. Pharmacologic Assisted Intubation <ul><li>Disadvantages/Potential Complications </li></ul><ul><ul><li>Does not provide sedation, amnesia </li></ul></ul><ul><ul><li>Provider unable to intubate, ventilate after NMB </li></ul></ul><ul><ul><li>Aspiration during procedure </li></ul></ul><ul><ul><li>Difficult to detect motor seizure activity </li></ul></ul><ul><ul><li>Side effects, adverse effects of specific drugs </li></ul></ul>
    80. 82. Pharmacologic Assisted Intubation <ul><li>Common Used NMB Agents </li></ul><ul><ul><li>Depolarizing NMB agents </li></ul></ul><ul><ul><ul><li>succinylcholine (Anectine®) </li></ul></ul></ul><ul><ul><li>Non-depolarizing NMB agents </li></ul></ul><ul><ul><ul><li>vecuronium (Norcuron®) </li></ul></ul></ul><ul><ul><ul><li>rocuronium (Zemuron®) </li></ul></ul></ul><ul><ul><ul><li>pancuronium (Pavulon®) </li></ul></ul></ul>
    81. 83. Pharmacologic Assisted Intubation <ul><ul><li>Summarized Procedure </li></ul></ul><ul><ul><ul><li>Prepare all equipment, medications while ventilating patient </li></ul></ul></ul><ul><ul><ul><li>Hyperventilate </li></ul></ul></ul><ul><ul><ul><li>Administer induction/sedation agents and pretreatment meds (e.g. lidocaine or atropine) </li></ul></ul></ul><ul><ul><ul><li>Administer NMB agent </li></ul></ul></ul><ul><ul><ul><li>Sellick maneuver </li></ul></ul></ul><ul><ul><ul><li>Intubate per usual </li></ul></ul></ul><ul><ul><ul><li>Continue NMB and sedation/analgesia prn </li></ul></ul></ul>
    82. 84. Pharmacologic Assisted Intubation <ul><li>Failure is not an option! </li></ul>
    83. 85. ALS Airway/Ventilation Methods <ul><li>Needle Thoracostomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Positive signs/symptoms of tension pneumothorax </li></ul></ul></ul><ul><ul><ul><li>Cardiac arrest with PEA or asystole with possible tension pneumothorax </li></ul></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>Absence of indications </li></ul></ul></ul>
    84. 86. ALS Airway/Ventilation Methods <ul><li>Tension Pneumothorax Signs/Symptoms </li></ul><ul><ul><li>Severe respiratory distress </li></ul></ul><ul><ul><li> or absent lung sounds (usually unilateral) </li></ul></ul><ul><ul><li> resistance to manual ventilation </li></ul></ul><ul><ul><li>Cardiovascular collapse (shock) </li></ul></ul><ul><ul><li>Asymmetric chest expansion </li></ul></ul><ul><ul><li>Anxiety, restlessness or cyanosis (late) </li></ul></ul><ul><ul><li>JVD or tracheal deviation (late) </li></ul></ul>
    85. 87. ALS Airway/Ventilation Methods <ul><li>Needle Thoracostomy </li></ul><ul><ul><li>Prepare equipment </li></ul></ul><ul><ul><ul><li>Large bore angiocath </li></ul></ul></ul><ul><ul><li>Locate landmarks: 2nd intercostal space at midclavicular line </li></ul></ul><ul><ul><li>Insert catheter through chest wall into pleural space over top of 3rd rib (blood vessels, nerves follow inferior rib margin) </li></ul></ul><ul><ul><li>Withdraw needle, secure catheter like impaled object </li></ul></ul>
    86. 88. ALS Airway/Ventilation Methods <ul><li>Chest Escharotomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Presence of severe edema to soft tissue of thorax as with circumferential burns </li></ul></ul></ul><ul><ul><ul><li>inability to maintain adequate tidal volume, chest expansion even with assisted ventilation </li></ul></ul></ul><ul><ul><li>Considerations </li></ul></ul><ul><ul><ul><li>Must rule out upper airway obstruction </li></ul></ul></ul><ul><ul><ul><li>Rarely needed </li></ul></ul></ul>
    87. 89. ALS Airway/Ventilation Methods <ul><li>Chest Escharotomy </li></ul><ul><ul><li>Procedure </li></ul></ul><ul><ul><ul><li>Intubate if not already done </li></ul></ul></ul><ul><ul><ul><li>Prepare site, equipment </li></ul></ul></ul><ul><ul><ul><li>Vertical incision to anterior axillary line </li></ul></ul></ul><ul><ul><ul><li>Horizontal incision only if necessary </li></ul></ul></ul><ul><ul><ul><li>Cover, protect </li></ul></ul></ul>
    88. 90. Airway & Ventilation Methods <ul><li>Saturday’s class </li></ul><ul><ul><li>Practice using equipment </li></ul></ul><ul><ul><ul><li>orotracheal intubation </li></ul></ul></ul><ul><ul><ul><li>nasotracheal intubation </li></ul></ul></ul><ul><ul><ul><li>gastric tube insertion </li></ul></ul></ul><ul><ul><ul><li>surgical airways </li></ul></ul></ul><ul><ul><ul><li>needle thoracostomy </li></ul></ul></ul><ul><ul><ul><li>combitube </li></ul></ul></ul><ul><ul><ul><li>retrograde intubation </li></ul></ul></ul>

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