1. Airway management DISAINER AND PRESENTER : MAJIDI ALIREZA (Resident of EMERGENCY MEDICIN) MAJIDY ALIREZA EMERGENCY MD

2. Advanced Airway Methods Airways( oral, nasal) Bag-mask ventilation Endotracheal intubation LMA MAJIDY ALIREZA EMERGENCY MD

4. An oxygen reservoir is required in order to give the patient oxygen concentrations greater than 60 % MAJIDY ALIREZA EMERGENCY MD

6. Two person bag-valve-mask ventilation (can achieve bigger ventilation volumes than by one person) MAJIDY ALIREZA EMERGENCY MD

7. ETI Decision to intubate Identification of dificult air way Anatomy of the airway Equipment laryngoscope (blades, Miller, Macintach) Equipment laryngoscope (blades, Miller, Macintach) Technique Check and secure MAJIDY ALIREZA EMERGENCY MD

8. Discision to Intubate should be based on assesment to three essential criteria. 1)Fuilure to maintain or protect the airway This approach is to evaluate the patients ability to phonate, level of consciousness, ability to manage own secretions. Presence or absence of gag reflex not corresponds to airway protective reflexes or need for intubation, because gag in 12% to 25% of normal adults is absent. MAJIDY ALIREZA EMERGENCY MD

9. 2)Fuilure of ventilation or oxygenation This assesment is clinical and include: 1)Evaluation of Pt general status 2)Oxygenation by pulse oximetry 3)Change in the ventilatory pattern ABG are not Indication for determination the patient need for Intubation. MAJIDY ALIREZA EMERGENCY MD

10. 3)Anticipated Clinical Course Severe TCA overdose maybe indicated Intubation. Multiple truma maybe indication for Intubation. Penetrating neck truma may present with evidence of vasculor or airway injury and increasing hemorrhage or swelling in neck and compromise the airway. MAJIDY ALIREZA EMERGENCY MD

11. Identification of difficult air way: The difficult Intubation is determined by LEMON Evaluation. MAJIDY ALIREZA EMERGENCY MD

13. Look externaly MAJIDY ALIREZA EMERGENCY MD

14. Evaluate 3-3-2 rule MAJIDY ALIREZA EMERGENCY MD

15. Evaluate 3-3-2 rule MAJIDY ALIREZA EMERGENCY MD

17. Cormack & Lehane Grading MAJIDY ALIREZA EMERGENCY MD

18. Obstruction Supraglotic obstruction such as: Epiglottitis, tumor, lud wig ’ s angina, neck Hematoma, glotic polyps can compromise larengoscopy,passage of the ETT, BMV or all three. : MAJIDY ALIREZA EMERGENCY MD

19. Obstruction MAJIDY ALIREZA EMERGENCY MD

20. Neck mobility Is assessed by having the patient flex and extend the head and neck. Modest limitatioins of motion don ’ t seriously impair larynogoscopy, but sever loss of motion may laryngoscopy impossible. MAJIDY ALIREZA EMERGENCY MD

21. Neck mobility MAJIDY ALIREZA EMERGENCY MD

22. You need to align the axes of the mouth, pharynx, and trachea for intubation to be successful ; these axes are not aligned when the neck is flexed MAJIDY ALIREZA EMERGENCY MD

23. Good alignment of the mouth, pharynx, and tracheal axes for intubation MAJIDY ALIREZA EMERGENCY MD

29. Intubation equipment to have ready MAJIDY ALIREZA EMERGENCY MD

30. Routine use of a stylet is recommended for intubation of both adults and children MAJIDY ALIREZA EMERGENCY MD

32. Choice of Laryngoscope Blades Straight blade (such as Miller) used to directly lift the epiglottis May be best if "floppy" epiglottis suspected (which is more common in children)best Curved blade (such as Macintosh) used to indirectly expose the glottic inlet by lifting up from the valleculavallecula Should have both available since unpredictably sometimes one works better than the other for some patients MAJIDY ALIREZA EMERGENCY MD

34. Laryngoscopic view with the straight blade (left) and the curved blade (right) MAJIDY ALIREZA EMERGENCY MD

36. Correct endotracheal tube positioning using a curved blade MAJIDY ALIREZA EMERGENCY MD

38. How to tape secure an oral endotracheal tube MAJIDY ALIREZA EMERGENCY MD

39. Another “backup” technique: placing an endotracheal tube down the lumen of the intubating LMA (laryngeal mask airway) MAJIDY ALIREZA EMERGENCY MD

42. RSI (Rapid Sequence Intubation) RSI is the corner stone of modern Emergency airway management. All patients who require intubation but who have neither a crash airway nor adifficult airway RSI is recommended. Is define as the administration of a potent sedative agent and NMB (succinyl choline) for the purpose of ETI. Is the safest and quickest method of achiving in such patients. MAJIDY ALIREZA EMERGENCY MD

44. 1. Pre Paration Is assesed for intubation difficulty and planing of dosage and sequence of drugs, tube size, luryngoscope blade and size. MAJIDY ALIREZA EMERGENCY MD

45. 2. Pre Oxygenation Adminestration of 100% oxygen for 3 minute permit 8 minute of apnea before oxygen desaturation to less than 90% occurs. If time is insufficient for a full 3 minute, pre oxygenation phase, for 8 vital capacity breaths is enough. MAJIDY ALIREZA EMERGENCY MD

46. 3. Pre Treatment MAJIDY ALIREZA EMERGENCY MD

47. 4. Paralysis with Induction In this pahse potent sedative agent is adminestered and Followed by rapid adminestration of NMBA (succinyl cholin) MAJIDY ALIREZA EMERGENCY MD

48. 5. Placement of tube 45 seconds after the administeratoin of succinyl choline, the patient is relaxed to permit laryngoscopy. Sellick ’ s maneuver during BMV of paralyzed patient that 02 saturation Fall below 90% must continued for prevention of passage air in to the stomach. As soon as the ETT is placed, the cuff should be inflated MAJIDY ALIREZA EMERGENCY MD

49. 6. Post Intuabation Management To confirm intubation should be done: CXR Chest auscultation Gastric auscultation capnography We should consdider complicatoin of ETT that seen esophageal intubation and resultant hypoxic brain injury. Long acting NMBA and sedative agent are indicated. MAJIDY ALIREZA EMERGENCY MD