1. Seldinger Cricothyrotomy Review 2005 ACP Recert (Enhansed)

2. What is an Indication for Intubation? –  LOC –Obtain / Maintain / Protect Airway –Oxygenation –Positive Pressure Ventilation or control ventilation –Drugs (NAVEL) –  Fatigue –Access Tracheal Toilet (suction)

3. Next Determination ? Once the decision to intubate has been made a then what? t Is it a CRASH intubation? –Death or near death (like “NIKE” “just do it”) –Suction, stylette, lubed ETT, stethoscope, laryngoscope t If time permits assess for DIFFICULT intubation using? –LEMON

4. CRASH AIRWAY t VSA t Pending VSA t Respiratory Arrest t GCS < 5 t Airway compromise (blood / vomit unable to clear) Note: positioning is the number 1 airway procedure to prevent aspiration.

5. Difficult Airway Assessment t L - Look1 point t E - Evaluate2 points t M - Mallampati (1 - 4)2 points t O - Obstruction2 points t N - Neck1 point 2 or more equals difficult If a difficult airway has been assessed be cautious about sedation

6. LEMON t L - Look (visual assessment)1 point (each) –Under / over bite –Big teeth –Facial hair –No neck –Barrel chest Gut feeling tough tube!!!

7. LEMON t E - Evaluate2 points –Ability to open mouth 3 fingers –Anterior Larynx 3 fingers –Superior Larynx 2 fingers Children and Asians have anterior and superior larynx.

8. LEMON t M - Mallampati (1 - 4) = 0 or2 points –1 = can see all of uvula –2 = can see most of uvula –3 = can see a part of uvula –4 = can see none of uvula - all hard palate Paramedics should lean to a 1 or 4 interpretation.

9. LEMON t O - Obstruction2 points –Tumors –Hematoma –Swelling

10. LEMON t N - Neck1 point –Immobility, unable for flex or extend neck –C -spine precautions –Kyphosis –Osteoporosis –Severe Rheumatoid Arthritis 2 or more equals difficult airway is expected

11. What if it is difficult? t Concern for paralytics and heavy use of analgesics and sedatives. If patient quits breathing and you are unable to ventilate - you have broken fundamental premise of medicine “CAUSE NO HARM”. t Before taking TOTAL control of a patient’s airway an accurate / defendable assessment for due diligence AND a back up must be available. t Blind nasal intubation with slight sedation may be beneficial.