1. CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

2. Objectives Review Anatomy and Physiology Review the approach to the difficult airway Review the protocols associated with difficult and failed airway management Review the difficult and failed airway algorithms CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

3. A&P Review Upper airway Nasopharynx Oropharynx Laryngopharynx Larynx CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

4. A&P Review Glottic structures Glottic opening Vocal cords Cuneiform cartilage Corniculate cartilage CAP Module 4 - Difficult Airway Management (GHEMS_April2015) Together make up the Arytenoid Cartilage

5. A&P Review Laryngeal landmarks Thyroid cartilage Cricothyroid membrane Cricoid membrane Thyroid gland CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

6. Airway Management – Difficult Airway Indications: All Prehospital airways should be considered difficult to some degree. The provider must have preexisting criteria for predicting possible difficult airway situations and a set algorithm based on agency resources and County protocols for managing the difficult airway. Critically ill patients will de-saturate quickly, possibly resulting in a failed airway situation. CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

7. Airway Management Approaching the Difficult Airway Predicting Use the LEMON pneumonic L - Look Externally E - Evaluate with 3-3-2 rule M - Mallampati score O - Obstruction N - Neck mobility CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

8. Look Externally For every patient who may require intubation, the paramedic should always look for readily apparent, even cosmetic, characteristics that may predict a potentially difficult airway. These include among others; obesity, micrognathia, evidence of previous head and neck surgery or irradiation, presence of facial hair, dental abnormalities (poor dentition, dentures, large teeth), a narrow face, a high and arched palate, a short or thick neck, and facial or neck trauma. CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

9. External look CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

10. 3-3-2 Rule CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

11. Mallampati Score Mallampati, Cormack and Lehane scores CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

12. Obstruction Foreign body Trauma Swelling Esophageal spasms Growth Infection CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

13. Obstruction list discussion Foreign body – remove by direct laryngoscopy and Magill forceps Trauma – Follow protocols and airway algorithms Swelling – Follow protocols and airway algorithms Esophageal spasms – Use of Succinylcholine Growth – Follow protocols and airway algorithms Infection – Follow protocols and airway algorithms CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

14. Neck Mobility Arthritis Spinal immobilization Location of patient Entrapment – discuss possibilities CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

15. Decision Making Question One Is Ventilation Adequate or Inadequate? Question Two Is the Airway Normal or Disrupted? CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

16. Decision Making: Ventilation Adequate Inadequate  SaO2 > 90%  Also note respiratory rate, effort  EtCO2 spot reading may be unhelpful (e.g. CO2 retainers)  SaO2 < 90%  Note baseline may be below 90%  Also note respiratory rate, effort CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

17. Decision Making: Airway Normal Airway Disrupted Airway Still identified as technically difficult Anatomy intact Examples: Obesity Anterior glottis Small mouth Still identified as technically difficult Abnormal anatomy Examples: Trauma/burn Infection Hematoma Cancer Foreign body CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

18. Decision Making: Resources Supraglottic Infraglottic Combitube PROC 120 Eschmann catheter (“bougie”) PROC 100 Percutaneous cricothyrotomy (Rusch quicktrach) PROC 290 Surgical cricothyrotomy PROC 290 CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

19. Combitube Protocol PROC-120 CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

20. Eschmann Catheter Protocol PROC-100 CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

21. Surgical Cricothyrotomy Protocol PROC-290 CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

22. Airway Management – Difficult Airway Approaching the Difficult Airway Call for additional assistance Maximize your chances Position, medications, dentures out if needed Have a PLAN 1. BVM/airway adjuncts 2. RSI 3. Partner tries or second try with different blade 4. ET introducer “Eschmann catheter” 5. Multi-Lumen Airway “combitube” CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

23. Difficult Airway Algorithm Call for additional assistance Move to failed airway algorithm Follow post intubation protocol RSI completed Able to BVM Pt w/adjuncts Use Eschmann Catheter RSI Completed Move to failed airway algorithm Try with a different blade/partner tries RSI completed Yes No Yes No Yes CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

24. Airway Management – Failed Airway  Indications: provider is unable to secure a definitive airway.  Definition  Oxygen saturation is below 90% after one attempt at ETT OR  Three failed attempts at ETT  Management  Combitube: bridging airway until definitive airway is placed  Cricothyrotomy: surgical airway is definitive, non- surgical (e.g. “quicktrach”) is not CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

25. Failed Airway Algorithm Failed Airway criteria met Call for assistance Cricothyrotomy Consider Combitube Able to BVM patient? Able to maintain SpO2>90% Arrange for definitive Airway Management Time allows and successful? Yes No CAP Module 4 - Difficult Airway Management (GHEMS_April2015)

26. Airway Management Questions? CAP Module 4 - Difficult Airway Management (GHEMS_April2015)