Presentation on theme: "By: Parrish T. Eilers, MD LSU Emergency Medicine"— Presentation transcript:
1By: Parrish T. Eilers, MD LSU Emergency Medicine AirwayBasicsBy: Parrish T. Eilers, MDLSU Emergency Medicine
2AirwaysThe Emergency Medicine Physician should be proficient in the assessment and management of all types of patient airways, regardless of age, gender, or level of difficulty.
3Goals By the end of this lecture, students should able to: A) Properly assess a patient’s airway.B) Discuss techniques for properly ventilating a patient.C) Identify tools and proper technique needed for intubating a patient.D) Discuss RSI
4Why do I need to intubate this patient? 1) Failure to oxygenate or ventilate2) Unable to protect their airway3) Expected Clinical Course
5Airway AssessmentThe first step needed before intubating any patient, should be to assess their airway.Steps needed for airway assessment, should start with can I properly ventilate this patient
6Ventilation vs Intubation Ventilation is the exchange of air between the lungs and the environment, including inhalation and exhalation.Endotracheal Intubation is the placement of an airway into the trachea for airway maintenance.
7Ventilation Requirements for bag mask ventilation: Need to have an open airwayNeed to have a proper mask seal between the patient and your mask
8MOANS Evaluating for bag mask ventilation difficulty MOANS M: Mask SealO: ObesityA: Age(>50 years)N: Neck MobilityS: Stiff(ie lung stiffness)
9Bag Mask VentilationPatients should ideally be supine in the “sniffing” positionMask should cover the nose and mouth of the patientBring the patient’s face UP to the mask, by holding onto the mandible, not the soft tissue under the chin. Don’t push the mask down on a patient’s face.Can use oral or nasal pharyngeal airways to assist with baggingTwo rescuer technique is best
15IntubationAfter assessing the airway, begin by looking down at the patient’s face from above the head. Then you gently scissor open the patient’s mouth, with your right hand. With the laryngoscopic blade in your left hand, insert it into the right side of your patient’s mouth and advance it along the tongue. If using a MAC blade, advance to the base of the tongue or the vallecula and sweep the tongue to the left. While doing this you’re also pulling your blade towards their feet. If using the Miller blade, then advance to the epiglottis and place the tip of your blade on the epiglottis. Then you sweep the tongue to the left and pull your blade towards your patient’s feet, lifting the epiglottis. Your Goal is just below the epiglottis.
18Rapid Sequence Intubation RSI 1) Preparation2) Preoxygenation3) Pretreatment4) Paralysis with Sedation5) Protection of Airway(Sellick manuver)6) Pass the Tube( with Confirmation)7) Postintubation Management
19PreparationPreparation is key to intubating your patient and should begin before your patient even arrives at the hospital.
20Tools Needed for Intubation Oxygen with Bag/Mask and NRBSuctionEndotracheal tubesOral and Nasal AirwaysSyringeLaryngoscope Blade with working HandleBougie, LMAMask with Face shield and GlovesSurgical airway Equipment
21PreoxygenationAll patient’s should be pre-oxygenated with 100% O2 by NRB or Bag/Mask for 2 minutes prior to intubation, even if they’re sats are 100% by NC O2.Because you want to blow off as much Nitrogen as possible and saturate your patient’s alveoli with oxygen.
22PretreatmentGive drugs to aid with the physiologic responses of intubationLidocaine blunts bronchospasm and the reflex responseOpioid(Fentanyl) blunts reflex responseAtropine to avoid bradycardia in kids receiving SuccinylcholineDepolarizing Agent----- to attempt to prevent fasciculations
23Paralysis with Sedation Give your RSI drugs, sedation first and then your paralytic. Usually pushed one right behind the other.Common ParalyticsSuccinylcholineRocuroniumCommon SedativesEtomidateKetamineAtivanVersed
24ProtectionThe airway is usually protected by using the Sellick maneuver or cricoid pressure, during paralysis, intubation, and confirmation of tube placement. The cricoid ring is compressed with the assistant’s index finger and thumb.
25Passage of the TubeThe tube is placed by direct visualization of the tube passing through the vocal cords. Inserted to a distance of about 3 times the tube size. Usually about 24cm in adult males and about 21 in adult females. Verify tube placement by watching the tube go through the cords, CO2 detector, auscultation of bilateral breath sounds, and CXR.
26Postintubation MgmtDon’t forget long term sedation and vent settings. Also don’t forget to check your postintubation CXR.