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Rich Levitan - Extreme Airways


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Rich Levitan’s talk on difficult airway management is part science, part philosophy and part pep talk.

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Rich Levitan - Extreme Airways

  1. 1. Thank you
  2. 2. EXTREMEAirways Crisis Performance..Rethinking our Approaches finding landmarks hypoxia cric Richard Levitan @airwaycam Stress & Fear fluids
  3. 3. Call for help! Call for help!
  4. 4. ENGINE FAILURE DURING FLIGHT 1.FAILED ENGINE CONDITION LEVER - FEATHER & FUEL SHUT-OFF. 2.Operative engine power lever - ADVANCE, as required. 3.Gear - UP. 4.Flaps - UP. 5.Maintain minimum single-englne speed or above. 6.Stores - JETTISON, as required. 7.Attempt air starts. 8.Failed engine power lever - FLIGHT IDLE. 9.Failed engine FUEL EMERG SHUT OFF - SHUT OFF. FAILURE OF BOTH ENGINES IN FLIGHT 1.Maintain 130 KIAS. 2.Fuel quantity - CHECK. 3.Attempt air starts. ELECTRICAL FIRE 1. Generators - OFF. 2. BATTERY - OFF. 3. RAM AIR knob - PULL FULL OUT. 4. All electrical equipment - OFF. 5. BATTERY - ON. 6. Generators - RESET separately. 7. Voltammeter - CHECK during generator reset. 8. Defective equipment - ISOLATE. incremental steps… 1st steps very important To do two things at once is to do neither. —Publilius Syrus
  5. 5. one step at a time… overcoming extremes
  6. 6. WHEN THERE IS A PERCEIVED IMBALANCE BETWEEN THE DEMANDS OF THE EMERGENCY AND YOUR PERCEPTION OF YOUR ABILITY TO MEET THOSE DEMANDS. STRESS: Increased heart rate > compromises fine motor skills > affects breathing, vision, and fatigue STRESS: impedes judgement, impairs focus, goofy loop—stuck on stupid. PERFORMANCE STRESS PERCEPTION PERCEPTION PERCEPTION PERCEPTION
  7. 7. Intubation: Do you see the cords? Hypoxia: Can you bag the patient? Cric: Can you feel the CTM? WRONG QUESTIONS! we’re rushing….slow is smooth, smooth is fast
  8. 8. Intubation: Do you see the cords?
  9. 9. Accept reality and responsibility Control your thoughts: Self-talk Control physical response to stress: Breathing and muscle relaxation techniques, stabilization of hands, biomechanics. Process insight: One step at a time Procedural insights: Pre-oxygenation & apneic oxygenation Positioning to optimize oxygenation Positioning to reduce regurgitation Ear-to-sternal notch positioning Mechanics of the upper airway Epiglottoscopy Progressive landmark exposure Bimanual laryngoscopy Opto-mechanics of tube delivery
  10. 10. Oxygenation is PRIORITY—not plastic Vomit—active/passive—is THE enemy of direct/video laryngoscopy, mask, LMA/King, passive oxygenation & fiberoptics—every part of the process
  11. 11. - 2 finger grip at base of handle - Scissor opening mouth - Roll blade down tongue - Visualize uvula - Yankauer suction hypopharnyx - Lift tongue and jaw - Visualize epiglottis - Check tongue position - Blade right, tongue left - Full grip on handle, thumb up - Blade aligned with forearm - Advance tip into vallecula - Bimanual laryngoscopy - Move larynx side to side - Move larynx posteriorly - Repeat suctioning as needed - Use assistant’s hand as needed - Head elevation as needed - Bougie or straight-to-cuff stylet - Insert into right corner of mouth - Place behind maxilla, move to larynx - Pivot tube or bougie corner mouth - Advance tip over notch - Tracheal ring impaction > Rt turn - 21-23cm at teeth male/female - Inflate cuff, end-tidal CO2, pulse ox Epiglottoscopy Laryngoscopy Tube delivery
  12. 12. Introduction & Epiglottoscopy and Controlling Tongue First Stage: 2 Fingers
  13. 13. Keys to Epiglottoscopy ★ – Proceed slowly, methodically midline down tongue ★ – Distract tongue and jaw forward, and lift epiglottis edge off the posterior pharynx ★ – A light grip allows fine adjustment and fine tongue control Beware of epiglottis camouflage ! fluids, blood, saliva pool in hypopharynx – use suction tip if needed to clear hypopharynx and see epiglottis edge epiglottis: - reliable anterior landmark - able to be lifted out of fluids - top of laryngeal inlet
  14. 14. Epiglottoscopy
  15. 15. Epiglottoscopy: The Secret to the Airway Any Device—One Approach…find the epiglottis on insertion Storz DCI Video Laryngoscope
  16. 16. Compartmentalize and then flatten the slope: Reduce each section of the procedure to its basic components Individual steps are small, reliable, achievable, & reproducible. Lighten the load (Mindset): Keep the wheelbarrow light and balanced Engineering Procedural Teaching & Training for Crisis Performance Tube delivery Laryngoscopy Epiglottoscopy 2 finger grip roll midline down tongue dab uvula, palatal arch, epiglottis tongue control bimanual head lift shape, bevel, rings ear - sternal notch face plane parallel to ceiling
  17. 17. Hypoxia: Can you bag the patient?
  18. 18. 36% of unconscious, non-paralyzed patients have complete UAO and 54% had partial UAO when the head was in the neutral position (Safar) Lesson from Bromiley case: Failure to cut or… wrong approach to oxygenation?
  19. 19. The NOSE is BETTER ! • No cheek flap • No pressure on unstable joint (jaw) • Nasal has better ventilation volumes vs oral/nask mask • Soft palate functions as emergency exit door Anesthesiology, V 108, No 6, Jun 2008 Liang et. al NASAL MASK ORAL- NASAL MASK Can 15 lpm unobstruct airway?
  20. 20. Soft palate Epiglottis Tongue Base upright–good for alveoli, diaphragm, fluids passive patent airway is via the nose pull mandible to unobstruct base of tongue, epiglottis O’s Up the Nose Pull mandible forward
 Sit patient up Oxygen On Pull mandible Sit patient up OOPS Cords
  21. 21. If you must ventilate… 1) Upright 2) Continuous flow O2 NC 3) PEEP valve Maximizes FiO2 and alveolar-capillary absorption
  22. 22. Cric: Can you feel the CTM?
  23. 23. Mental Armor Will I cause harm? Do I have the skill set? Am I sure where to cut? Is it really needed? The Surgically Inevitable Airway The Cartilaginous Cage The Laryngeal Handshake Sternal Stabilization Save a Life… Cut the neck.
  24. 24. back wall of the cricoid cartilage a firm stop... so don’t be fearful ! Cricoid ring front: 2.5-5.0 mm Back wall: 16 - 29 mm
  25. 25. a firm stop... so don’t be fearful ! Cricoid ring front: 2.5-5.0 mm Cricoid back wall: 16 - 29 mm 2.5-5.0 mm 16-29 mm
  26. 26. “The Laryngeal Handshake” …rock the rhomboid
 5 fingers >>>> not 1 finger Find midline >>>> not the CTM >>> vertical cut, then verify location CTM Epiglottis = the center of the world in the internal airway Thyroid = center of the world for external laryngeal landmarks
  27. 27. Save a life & cut the neck! Rock the Rhomboid! Rock the Rhomboid! Save a life & cut the neck! Rock the Rhomboid!
  28. 28. 1. Laryngeal handshake 2) Non-dominant stabilizes larynx 3) vertical incision 4) verify CTM with finger 4) Sternal stabilization
  29. 29. Incrementalize Your Procedures Performance Stress Beauty / Death Ratio Celebrate the Victories Richard Levitan @airwaycam