Presentation is loading. Please wait.

Presentation is loading. Please wait.

New Orleans EMS Airway Lecture Series: Lecture 1 Predicting the Difficult Airway Jeffrey M. Elder, M.D. Deputy Medical Director.

Similar presentations


Presentation on theme: "New Orleans EMS Airway Lecture Series: Lecture 1 Predicting the Difficult Airway Jeffrey M. Elder, M.D. Deputy Medical Director."— Presentation transcript:

1 New Orleans EMS Airway Lecture Series: Lecture 1 Predicting the Difficult Airway Jeffrey M. Elder, M.D. Deputy Medical Director

2 When To Intubate? Failure to maintain/protect the airway – Required for successful oxygenation and ventilation – Reflexes avoid aspiration – Clear vocal communication is a good measure for airway protection/patency – Absence of a gag reflex not sensitive or specific as indicator for the need of an airway (swallowing) Swallowing requires sensing the presence of pooled material and complex muscular actions to swallow – Spontaneous respirations ≠ airway protection

3 When To Intubate? Failure of Ventilation or Oxygenation – Supplemental oxygen not effective: ARDS – Respiratory fatigue/failure: Asthma – Can be reversible: Opioid overdose

4 When To Intubate? Anticipated Clinical Course – Deterioration of the critically ill – Patient is exposed to a period of increased risk: Long transport time, air evacuation, etc. – Requires clinical gestalt Examples: – Head injury/combative – Expanding hematoma

5 Approach to Evaluating the Airway Ask a question: What is your name? – Response can tell you about airway and neurological status – Normal voice, ability to inhale and exhale in a manner required for speech, comprehending the question – Only tells you about 1 moment in time – If unable to phonate properly: perform a detailed assessment of the airway

6 Approach to Evaluating the Airway Examine Mouth and Oropharynx – Bleeding – Swelling of Mouth or Uvula – Any abnormality that would interfere with the passage of air Examine Mandible and Central face integrity

7 Approach to Evaluating the Airway Examine the Anterior Neck, Larynx, and Trachea: – Palpate for subcutaneous air Tracheal injury, pulmonary injury, esophageal rupture, gas forming infections Monitor the Respiratory Pattern – Stridor = upper airway obstruction

8 Approach to Evaluating the Airway Observe the chest through several respiratory cycles – Look for symmetrical, concordant chest movement – Paradoxical movement or flail chest – Diaphragmatic breathing – spinal cord injury

9 Approach to Evaluating the Airway Auscultation of the chest – Assess adequacy of air exchange – Decreased breath sounds in hemothorax, pneumothorax, or other pulmonary process Monitor pulse oximetry, capnography, and mentation – ABGs rarely helpful in the decision to intubate Anticipate clinical course!

10 Identification of the Difficult and Failed Airway

11 The Failed Airway Failure to maintain acceptable oxygen saturation during or after on or more failed laryngoscopic attempts (CICO) or Three failed attempts at orotracheal intubation by an experienced intubator, even when oxygen saturation can be maintained.

12 Clinical presentations of the Failed Airway There is not sufficient time to evaluate or attempt a series of rescue options, and the airway must be secured immediately because of an inability to maintain O2 sats via BVM. (CICO) There is time to evaluate and execute various options because the patient is in a “can’t intubate, can oxygenate situation”

13 Four Technical Operations of the Difficult Airway Difficult Bag Valve Mask Ventilation – MOANS Difficult Laryngoscopy and Intubation – LEMON Difficult Extra-Glottic Device – RODS Difficulty Cricothyrotomy – SHORT

14 Difficult Bag-Mask Ventilation: MOANS Mask Seal Obstruction/Obesity Age >55 No Teeth Stiff lungs

15 Difficult Laryngoscopy and Intubation: LEMON Look Externally Evaluate Mallampati Score Obstruction/Obesity Neck Mobility

16 Difficult Laryngoscopy and Intubation: LEMON Look Externally Gestalt Gut Feeling First Impression – “This looks bad!”

17 Difficult Laryngoscopy and Intubation: LEMON Evaluate Rule: – Relates the mouth opening to size of the mandible to the position of the larynx in terms of likelihood of successful visualization of the glottis by direct laryngoscopy

18 Difficult Laryngoscopy and Intubation: LEMON Mouth must open adequately to permit visualization past the tongue when both the blade and ET tube are within the oral cavity The mandible must be sufficient size to allow the tongue to be displaced fully into the submandibular space The glottis must be located a sufficient distance caudad from the base of the tongue so that a direct line of site can be created to look from mouth to vocal cords as the tongue is displaced inferiorly

19 Difficult Laryngoscopy and Intubation: LEMON First “3” Assesses for mouth opening 3 fingers between the upper and lower incisors

20 Difficult Laryngoscopy and Intubation: LEMON Second “3” Length of the Mandibular space Mentum to hyoid

21 Difficult Laryngoscopy and Intubation: LEMON “2” Position of the glottis in relation to the base of the tongue Space from Chin-neck junction (hyoid) to and thyroid notch

22 Difficult Laryngoscopy and Intubation: LEMON Mallampati – Sitting Up – Head in sniffing position – Open mouth, protrude tongue without phonation Class I-IV Class I & II = low intubation failure rate Class III & IV = intubation failure may be > 10%

23 Difficult Laryngoscopy and Intubation: LEMON

24 Obstruction/Obesity Four Cardinal Signs of Upper Airway Obstruction: – Muffled voice – Difficulty swallowing secretions – Stridor – Sensation of dyspnea

25 Difficult Laryngoscopy and Intubation: LEMON Stridor – Occurs when airway circumference is less than 50% of normal (4.5mm or less) May quickly lead to total obstruction with administration of opiates or benzos – Loose the stenting of open airways Prepare for double set up

26 Difficult Laryngoscopy and Intubation: LEMON Neck Mobility – C spine immobilization may compound the effects of other difficult airway markers Trauma, RA, Ankylosing Spondylitis May require video laryngoscopy

27 Difficult Extraglottic Device: RODS Restricted Mouth Opening Obstruction Disrupted or Distorted Airway Stiff Lungs or Cervical Spine

28 Difficult Extraglottic Device: RODS Restricted Mouth Opening – Allowing for oral access to insert device

29 Difficult Extraglottic Device: RODS Obstruction – Upper airway obstruction at larynx or below

30 Difficult Extraglottic Device: RODS Disrupted or Distorted Airway – Seat/Seal compromised of the device

31 Difficult Extraglottic Device: RODS Stiff Lungs or Cervical Spine – Increased airway resistance Severe Asthma – Decreased pulmonary compliance Pulmonary Edema – Decreased Cervical Movement

32 Difficult Cricothyrotomy: SHORT Surgery or Disrupted Airway Hematoma (infection/abscess) Obesity Radiation Tumor

33 Difficult Cricothyrotomy: SHORT Surgery or Airway Disruption – Anatomy distortion – Halo Device

34 Difficult Cricothyrotomy: SHORT Hematoma – Infection – Trauma or Postop – Not a contraindication

35 Difficult Cricothyrotomy: SHORT Obesity – Access – Short neck – Large pannus – Subcutaneous Emphysema – Careful palpation to overcome!

36 Difficult Cricothyrotomy: SHORT Radiation – Distortion of Anatomy – Scar Tissue – Fixed Flexion Deformity of the Spine

37 Difficult Cricothyrotomy: SHORT Tumor – Extrinsic – Intrinsic

38

39 Acknowledgement Manual of Emergency Airway Management, 3 rd Edition. Walls, R. and Murphy, M


Download ppt "New Orleans EMS Airway Lecture Series: Lecture 1 Predicting the Difficult Airway Jeffrey M. Elder, M.D. Deputy Medical Director."

Similar presentations


Ads by Google