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![Cormack and Lehane[CL]
• The most widely used system for grading
laryngoscopic view of the glottis is that of
Cormack and Lehane (CL)
• Grades laryngoscopy according to the
extent to which laryngeal and glottic
structures can be seen.](https://image.slidesharecdn.com/airwaynbepresentation2017-170715093319/75/Airway-management-in-ER-nbe-presentation-2017-60-2048.jpg)
Uploaded byDr.Venugopalan Poovathum Parambil
Airway management in ER @ nbe presentation 2017
1) Airway management is a core skill in emergency medicine and the emergency physician has primary responsibility for airway management. Intubation should be considered when the airway cannot be protected or ventilated, or if clinical deterioration is anticipated. 2) Assessing the airway includes evaluating level of consciousness, ability to phonate, handle secretions, and anticipated clinical course. Ventilatory or oxygenation failure are also indications for intubation. 3) Confirmation of endotracheal tube placement includes methods like direct visualization, auscultation, end-tidal CO2 detection, ultrasound, and chest x-ray. Fiberoptic bronchoscopy is the gold standard.
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Airway management in ER @ nbe presentation 2017
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- 2. Airway management inER settings “Basic & Advanced” Updated with recent advances Dr.Venugopalan. P.P DA,DNB,MNAMS,MEM-GWU Director , Emergency Medicine Aster DM Healthcare PG teacher NBE Lecture ; NBE E learning program , July 2017
- 3. Why airway managementin Emergency Room ? • Airway management is the cornerstone of resuscitation • A defining skill for the specialty of emergency medicine • The emergency physician has primary responsibility for management of the airway • All airway management techniques lie within the domain of emergency medicine
- 4. When to intubate? • 1.Failure to maintain or protect the airway • 2.Failure of ventilation or oxygenation • 3.Anticipated clinical course and likelihood of deterioration. Clinical Decision
- 5. How do youknow airway is patent? • Level of consciousness • Ability to phonate in response to voice command or query (Integrity of the upper airway and the level of consciousness) • Ability to manage his or her own secretions ( pooling of secretions in the oropharynx, absence of swallowing spontaneously or on command)
- 6. Intubation? A patient whorequires a manoeuver to establish a patent airway or who easily tolerates an oral airway probably requires intubation for protection of that airway, unless temporary or readily reversible condition, such as opioid overdose, is present.
- 7. Ventilatory failure orOxygenation failure? • Clinical assessment • Pulse oximetry with or without capnography • Observation of improvement or deterioration in the patient’s clinical condition
- 8. The decision tointubate Intubate early especially in dynamic airways Bullets - neck trauma Bites- anaphylaxis / angioedema Burns -caustic airway injuries,Thermal injuries Three B ’s
- 9. Airway - mouthand neck infections, tumors, foreign bodies, bleeds stridor, phonation, swallowing, secretions, dyspnea Breathing- failure of oxygenation or ventilation often amenable to medical and non-invasive therapies – think NIV Circulation supporting tissue oxygen delivery by unloading the muscles of respiration sepsis A-B-C-D-E-F
- 10. A-B-C-D-E-F Disability : CNScatastrophes and CNS depression, ongoing seizures, weakness Avoid gag – assess ability to swallow and handle secretions (pooling, drooling, gurgling) for neuromuscular weakness: FVC < 12 ml/kg and NIF < 20 cm H20 vomiting in the obtunded patient is a particular concern Expected course:anticipated decline, transfer to radiology or another institution Feral -need for prompt, aggressive sedation to protect patient/others especially with potential or undiagnosed medical instability
- 11. Arterial blood gases(ABGs) generally are not required to determine the patient’s need for intubation
- 12. Anticipated clinical deterioration •Certain overdoses • Significant multiple trauma, with or without head injury • Multiple trauma with hypotension, an open femur fracture, and diffuse abdominal tenderness • Aggressive resuscitation, pain control, invasive procedures and imaging outside of the emergency department ,inevitable operative management • Evidence of vascular or direct airway injury in the neck
- 13. Obstructed airway ? Tongueand Epiglottis Any Foreign materials ? Clear it Noisy breathing ?
- 14.
- 15. Head tilt &Chinlift
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- 19. Airway Not – Maintainable? Adjuncts
- 20. Choice –OPA ! •Airway Reflexes ? …..No !
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- 22. Sizing - oropharyngealairway
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- 27. N P A •OPA is not tolerating ? • Airway reflexes retained ? • Inability to open mouth ?
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- 30. Airway Still not –Maintainable ? Advanced Airway
- 31. No Breathing ? E– C Clamp Place and hold mask properly
- 33.
- 35. Non-maintainable Airway R S I Conscious patient? Semiconsciouswith retained reflexes?
- 36. RSI Defined “Virtually simultaneousadministration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”
- 37. What are TheProblems Inherent to Intubation? • Laryngoscopy and Intubation – Increased bronchospasm – Increased ICP – Increased catecholamine release
- 38. Beneficial Effects ofRSI • “Tight Heads” – Intracranial pathology • “Tight Hearts” or “Tight Vessels” – Cardiovascular disease • “Tight Lungs” – Reactive airway disease
- 42.
- 45. RSI: Timeline T –10 minutes Prepare T – 5 minutes Preoxygenate T – 3 minutes Pretreat T = 0 Paralysis with induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation management
- 47. Problem Airway epiglottis Vocalcords Airway Evaluation
- 49. Double set up •Neuromuscular paralysis generally should be avoided in patients for whom a high degree of intubation difficulty is predicted, unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
- 51. Look Externally • Severelybruised • Bloodied face of a combative trauma patient • Immobilised in a cervical collar on a spine board • Anatomical deformities • Subjective clinical judgment can be highly specific (90%) but insensitive and so should be augmented by other evaluations.
- 54. Obstruction or obesity •Visualization of the glottis, or intubation itself, mechanically impossible • Epiglottis, head and neck cancer, Ludwig’s angina, neck hematoma, or glottic polyps • Examine the patient for airway obstruction and assess the patient’s voice to satisfy this evaluation step
- 55. Neck mobility • Neckmobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy. Neck mobility is assessed with the patient’s flexion and extension of the head and neck through a full range of motion
- 56. Lemon in ERsetting • Unresponsive patient - Mallampatti is not practical - LEON • Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
- 60. Cormack and Lehane[CL] •The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL) • Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen.
- 61. CL grading • Grade1 laryngoscopy, all or nearly all of the glottic aperture is seen. • Grade 2 laryngoscopy visualizes only a portion of the glottis (arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords). • Grade 3 laryngoscopy visualizes only the epiglottis. • Grade 4 laryngoscopy, not even the epiglottis is visible.
- 63. Percentage Of Glottic Opening(POGO) score
- 66. Confirmation of EndotrachealTube Placement • Direct visualisation • Chest auscultation • Gastric auscultation • Bag resistance • Exhaled volume • Visualization of condensation within the ETT • Chest radiography • All are prone to failure as means of confirming tracheal intubation.
- 67. ETCO2 • End-tidal carbondioxide (ETCO2) detection device to the ETT and assess it through six manual ventilations • Disposable, colorimetric ETCO2 detectors are highly reliable, convenient, and easy to interpret, indicating adequate CO2 detection by color change
- 68. End tidal CO2detection
- 70. USG- EDD • WhenETCO2 detection is not possible, tracheal tube position can be confirmed with other techniques. • One novel approach Bedside ultrasound.
- 71. USG guided Intubation andplacement confirmation
- 72.
- 73. EDD - howto work ?
- 74. Recognize Adequacy ofVentilations Pulse oximeter
- 75. Approximate Blood oxygenlevel ! ➢SpO2 100% = PaO2 100mm of Hg ➢SpO2 90%= PaO2 60mm of Hg ➢SpO2 60%= PaO2 30mm of Hg ➢SpO2 50%= PaO2 27mm of Hg
- 76. Chest X ray •Although chest radiography is universally recommended after ETT placement, its primary purpose is to ensure that the tube is well positioned below the cords and above the carina.
- 77. Other methods Goldstandard • Fiberoptic confirmation
- 78. Difficult Airway Assessment •4 D’s – Distortion, Disproportion, Dysmobility, Dentition • BONES – Beard, Obese, No teeth, Elderly, Snores (sleep apnea) • SHORT – Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor • LEMON • MALLAMPATI • Always have a “Rescue Airway” technique ready
- 79.
- 80. Rescue Airways • GumElastic Bougie (GEB) • Laryngeal Mask Airway (LMA/ILMA) • Combitube • Surgical Cricothyrotomy
- 81.
- 82. Gum elastic bouge •Useful only when larynges is visualise at least partially • Difficulty intubation • Tube changing • Provision to supplement oxygen
- 83. Advanced airway –Bestchoice Intubation
- 85. Equipments Needed ❑ Laryngoscopewith different types of blade. ❑ ET tube with proper size and type. Average adult male: 8.5 mm Average adult female: 7.5 mm Low pressure cuff tubes above 5 years Uncuffed tubes below 5 years < 4 Age + 3.5 3 > 4 Age + 4.5 4
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- 88. Align the airwayaxis by proper positions
- 89.
- 91.
- 94.
- 95. Cricoid pressure Pressure onCricoid cartilage Compress oesophagus between Cricoid ring and Vertebral column Prevent Regurgitation and Aspiration Make cord visualisation difficult Not recommended in Crash airway
- 96. External Laryngeal manipulation BURP -Backward - Upward - Right- Posterior Pressure over thyroid cartilage Better vocal cord visualisation A grade 3 larynx become grade 2 with ELM It is not Cricoid pressure
- 97. Blind insertion devices LMA,Combitube ,King’s airway
- 98. Laryngeal Mask Airway ❑Asilicone rubber device that combines. Tracheal intubation and the use of a face mask. ❑Used for situations when intubation attempts have failed, bag-valve mask ventilation is unsuccessful, and the patient needs immediate airway management.
- 99.
- 102. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09 LMA-Sizes Size Description Weight 1 Neonates Upto 5 Kg 1 ½ Pediatric 5 - 10 Kg 2 Infant 10 – 20 Kg 2 ½ Child 20-30 Kg 3 Large child/ Small Adult 30 – 50 Kg 4 Adult 50 – 70 Kg 5 Adult > 70 Kg
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- 106. Surgical Airway Needle Cricand Surgical Cric
- 107. Needle cric • Buyingtime in Emergency airway • Picture cricothyroid membrane • Provide some oxygenation • Proceed to surgical cric
- 111. Blind Nasotracheal Intubation •BNTI remains a valid method of intubation in the out-of-hospital setting, where it occasionally is used. In the ED, BNTI rarely, if ever, should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
- 113. Awake Oral Intubation •Awake oral intubation is a technique in which sedative and topical anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade. • Topical anesthesia may be achieved by spray, nebulization, or local anesthetic nerve block. After the patient is sedated and topical anesthesia has been achieved, gentle direct, video, or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
- 114.
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- 116. What is theDisaster in Airway management? Can’t Intubate ! Can’t Ventilate !!
- 117. LMA ,Combitube ,Bougie assisted intubation Surgical Airway • Rescue Airway
- 118.
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- 125. Airway management madeeasy Algorithms
- 132.