1.
Thank you

2.
EXTREMEAirways
Crisis Performance..Rethinking our Approaches
finding
landmarks
hypoxia
cric
Richard Levitan @airwaycam airwaycam@gmail.com
Stress
& Fear
fluids

3.
Call for help!
Call for help!

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.
one step
at a time…
overcoming
extremes

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.
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.
Intubation: Do you see the cords?

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.
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.
- 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.
Introduction & Epiglottoscopy
and Controlling Tongue
First Stage: 2 Fingers

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.
Epiglottoscopy

15.
Epiglottoscopy: The Secret to the Airway
Any Device—One Approach…find the epiglottis on insertion
Storz DCI Video Laryngoscope

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.
Hypoxia: Can you bag the patient?

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.
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.
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.
If you must ventilate…
1) Upright 2) Continuous flow O2 NC 3) PEEP valve
Maximizes FiO2 and alveolar-capillary absorption

22.
Cric: Can you feel the CTM?

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.
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.
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.
“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.
Save a life & cut the neck!
Rock the Rhomboid!
Rock the Rhomboid!
Save a life & cut the neck!
Rock the Rhomboid!

28.
1. Laryngeal handshake
2) Non-dominant stabilizes larynx
3) vertical incision
4) verify CTM with finger
4) Sternal stabilization

29.
Incrementalize Your Procedures
Performance Stress Beauty / Death Ratio
Celebrate the Victories
Richard Levitan @airwaycam airwaycam@gmail.com