GSACEP core man LECTURE series:

Airway management

Lauren Oliveira, DO

LT, MC, USNUpdated: 01MAR2013

Disclaimer

Views and opinions expressed do not necessarily reflect those of GS-ACEP, The Department of Defense, the U.S. Government, the North American Continent, the Western Hemisphere, or Mother Earth.

Objectives

Anatomy/PhysiologyAirway AssessmentAirway ManagementEquipment and MedicationsSkills Practice

Anatomy

Upper Airway

Anatomy

Lower Airway

Anatomy

Anatomy

physiology

Ventilation Inhaling and exhaling

Oxygenation Adding oxygen to the body

system

physiologyOxygen inHemoglobin on the RBCs carry O2 to the tissuesCarbon dioxide out

Airway assessment

Look, listen, feel (noisy is bad) Rate/Quality

Breathing fast? Working hard? Shallow breaths? Chest rising?

Airway assessment: Monitor

Pulse oximetry The “oxygenation” vital sign >94%

Capnography (End Tidal CO2) The “ventilation” vital sign 35-45mmHg

Airway assessment

Predicting a difficult Bag Valve Mask (BVM) Old No teeth Beard

Airway assessment

Predicting a difficult intubation Limited neck mobility Large tongue Facial trauma Malampati score

Airway management

One person in charge Assess, intervene, monitor

Airway management

Position Ear-to-sternal notch

Universal ventilation and intubation position

Independent of age and size

Airway management

Position

Head Tilt/Chin LiftJaw Thrust

(Maintains C-spine precautions)

Airway management

Unconscious/no gag reflex intubateConfused/combative patients are hypoxic until proven otherwise

Airway management

Cricoid pressure (Sellick maneuver) no longer recommended Aspiration still can occur Makes it difficult to ventilate…complete

AW occlusion in 11% Detrimental effects on view and blocks

tube passage MRI studies show esophageal occlusion

not reliable

Airway management

However, external manipulation of the thyroid cartilage by the person intubating is helpful to improve view

Equipment and medications

SOAP ‘EM Suction Oxygen (BVM ready and pre-

oxygenate) Airway adjuncts (OPA, NPA) Position End Tidal CO2 (Capnography or

colormetric device) Meds & Monitors

Equipment

SuctionOxygen Delivery Nasal cannula, simple mask, non-rebreather

Must be at least 10L/min

5-12L/min

Equipment

Bag Valve Mask (BVM) Connect to oxygen Squeeze against hand to verify

positive pressure

Equipment

Airway Adjuncts Nasopharyngeal airway

Okay in an awake patient Measure nose to ear lobe

Equipment

Airway Adjuncts Oropharyngeal airway

Only in a comatose patient (will gag) Measure corner of mouth to ear lobe

Equipment: Advanced airway

Endotracheal tube (ETT) and laryngoscope

Laryngoscope Handle

Tape to secure tube

Laryngoscope Blade (here is a Miller)

Syringe to inflate the cuff ETT and

Stylet

Equipment: advanced airway

LMA (Laryngeal Mask Airway)

Equipment: advanced airway

King LT

Equipment: advanced airway

Bougie

Equipment: advanced airway

Direct vs Video laryngoscopy

Equipment: advanced airway

Direct laryngoscopy

Equipment: advanced airway

Direct vs Video laryngoscopy

Equipment: advanced airway

1. Vertical incision through skin w/ scalpel

Cricothyroidotomy

Equipment: advanced airway

2. Horizontal incision through cricothyroid membrane

Cricothyroidotomy

Equipment: advanced airway

3. Bougie into opening

4. Slide 6-0 ETT over bougie, remove bougie and secure tube

Cricothyroidotomy

Equipment: advanced airway

5. Confirm placementGold= GoldenBreath sounds

Cricothyroidotomy

Equipment: medications

1st = Sedate Etomidate Ketamine Midazolam (or other benzodiazepine)

2nd = Paralyze Succinylcholine Rocuronium Vecuronium

Skills practice…Go!

Intubation set up O2, BVM, suction, pulse ox,

laryngoscope, tube(s), stylet, syringe, CO2

Medications Paralytics Sedatives

Rescue devicesCricothyroidotomy

Skills practice