1. GSACEP core man LECTURE series: Airway management Lauren Oliveira, DO LT, MC, USN Updated: 01MAR2013

2. 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.

3. Objectives Anatomy/Physiology Airway Assessment Airway Management Equipment and Medications Skills Practice

4. Anatomy Upper Airway

5. Anatomy Lower Airway

6. Anatomy

8. physiology Ventilation Inhaling and exhaling Oxygenation Adding oxygen to the body system

9. physiology Oxygen in Hemoglobin on the RBCs carry O2 to the tissues Carbon dioxide out

10. Airway assessment Look, listen, feel (noisy is bad) Rate/Quality  Breathing fast?  Working hard?  Shallow breaths?  Chest rising?

11. Airway assessment: Monitor Pulse oximetry  The “oxygenation” vital sign  >94% Capnography (End Tidal CO2)  The “ventilation” vital sign  35-45mmHg

12. Airway assessment Predicting a difficult Bag Valve Mask (BVM) Old No teeth Beard

13. Airway assessment Predicting a difficult intubation Limited neck mobility Large tongue Facial trauma Malampati score

14. Airway management One person in charge Assess, intervene, monitor

15. Airway management Position Ear-to-sternal notch  Universal ventilation and intubation position  Independent of age and size

16. Airway management Position Head Tilt/Chin Lift Jaw Thrust (Maintains C-spine precautions)

17. Airway management Unconscious/no gag reflex  intubate Confused/combative patients are hypoxic until proven otherwise

18. 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

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

20. 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

21. Equipment Suction Oxygen Delivery Nasal cannula, simple mask, non-rebreather Must be at least 10L/min 5-12L/min

22. Equipment Bag Valve Mask (BVM) Connect to oxygen Squeeze against hand to verify positive pressure

23. Equipment Airway Adjuncts Nasopharyngeal airway  Okay in an awake patient  Measure nose to ear lobe

24. Equipment Airway Adjuncts Oropharyngeal airway  Only in a comatose patient (will gag)  Measure corner of mouth to ear lobe

25. 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

26. Equipment: advanced airway LMA (Laryngeal Mask Airway)

27. Equipment: advanced airway King LT

28. Equipment: advanced airway Bougie

29. Equipment: advanced airway Direct vs Video laryngoscopy

30. Equipment: advanced airway Direct laryngoscopy

31. Equipment: advanced airway Direct vs Video laryngoscopy

32. Equipment: advanced airway 1. Vertical incision through skin w/ scalpel Cricothyroidotomy

33. Equipment: advanced airway 2. Horizontal incision through cricothyroid membrane Cricothyroidotomy

34. Equipment: advanced airway 3. Bougie into opening 4. Slide 6-0 ETT over bougie, remove bougie and secure tube Cricothyroidotomy

35. Equipment: advanced airway 5. Confirm placement Gold= Golden Breath sounds Cricothyroidotomy

36. Equipment: medications 1 st = Sedate Etomidate Ketamine Midazolam (or other benzodiazepine) 2 nd = Paralyze Succinylcholine Rocuronium Vecuronium

37. Skills practice…Go! Intubation set up O2, BVM, suction, pulse ox, laryngoscope, tube(s), stylet, syringe, CO2 Medications Paralytics Sedatives Rescue devices Cricothyroidotomy

38. Skills practice