Advanced airway
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The document discusses advanced airway management and intubation. It covers anatomic considerations for intubation, indications for definitive airways, rapid sequence induction procedures and medications, intubation techniques and tricks, and surgical airway options including cricothyrotomy and needle cricothyrotomy.
Advanced airway
- 1. Advanced Airway Lynn K. Wittwer, MD, MPD Clark County EMS
- 2. Advanced Airway Anatomic Considerations Rapid Sequence induction Induction Agents Intubation tricks
- 3. Indications for Definitive Airway Risk for obstruction Neck hematoma Laryngeal, tracheal injury/burn Stridor Severe closed head injury with need for hyperventilation Risk for aspiration Bleeding Vomiting Inadequate Respiratory Effort’ Tachypneal Hypoxia Hypercarbia Cyanosis Severe Maxillofacial fx’s Apnea Neuromuscular Paralysis Unconscious Unconscious Need for Ventilation Need for Airway Protection
- 4. Mouth: Tongue : variable in size (angioedema) attached inferior to epiglottis Mandible Uvula Pharynx Tonsils Merges with larynx anterior, esophagus posterior Epiglottis high long flaccid and narrow in child ANATOMIC CONSIDERATIONS FOR INTUBATION
- 5. The Larynx High relative to mandible in child Cricoid smaller in child, narrow part of airway vocal cord narrow part of adult airway arytenoid cartilages ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)
- 6. Netter; Atlas of Human Anatomy
- 7. Trachea 12-15 cm. Adult 4 cm. Newborn right mainstem larger,shorter and less angle ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.) Anderson; Grant’s Atlas of Anatomy
- 8. ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.) Anderson; Grant’s Atlas of Anatomy
- 9. Tube Sizes (Kids) Fit through nose Age(years)/4 + 4 Oral tube length Age(years)/2 + 12 cm. Nasal add 3 cm. No cuff under 6 to 8 years OTHER CONSIDERATIONS FOR INTUBATION (cont.)
- 10. Difficult tubes Immobilized trauma patient Combative patient Children, esp. Infants Short neck Prominent upper incisors Receding mandible Limited jaw opening, limited cervical mobility Upper airway conditions Facial, laryngeal trauma OTHER CONSIDERATIONS FOR INTUBATION (cont.)
- 11. Correct Placement for intubation (b)
- 12. Patient in correct position for intubation (sniffing position)
- 13. Incorrect airway position (hyperflexed)
- 14. Rapid Sequence Induction Indications Ventilatory failure Airway maintenance/protection Treatment and evaluation neuro resuscitation(hyperventilate) shock drug overdose
- 15. Contraindications Cardiac arrest Adequate ventilation Deeply comatose patient, absent tone Post-intubation sedation Rapid Sequence Induction
- 16. Contraindications (cont.) Intubation likely unsuccessful Partially obstructed airway Severe facial abnormality(trauma, etc.) Rapid Sequence Induction Whitten; Anyone Can Intubate
- 17. McIntyre; The difficult tracheal intubation
- 18. Maintain adequate oxygenation Airway protection Prevent regurgitation, aspiration Obtund adverse cardiovascular and ICP response to intubation Better early than late Hypoxemia and acidosis effects Rapid Sequence Induction
- 19. Treatment Algorithm Preparation Pre-oxygenation( functional reserve capacity) Pre-medication Sedation Cricoid pressure Paralysis Intubation Rapid Sequence Induction
- 20. DO NO HARM! TAKE AWAY NOTHING FROM THE PATIENT YOU CANNOT REPLACE
- 21. Anticipate the difficulties Identify in advance the patient who may require RSI Identify the patient with anatomic difficulty Have sufficient skill and training Have a preformulated plan for potential disaster Rapid Sequence Induction
- 22. Airway Evaluation Problem Airway epiglottis Vocal cords
- 23. Be prepared: Competence with all equipment Working equipment Be prepared for surgical management Master the art of bagging Have at least one, if not two, working IV lines Rapid Sequence Induction
- 24. Equipment: Suction, Oxygen Laryngoscope, ET Tubes, Stylet BVM Pharmacologic agents, mixed and ready Monitoring equipment Continuous cardiac monitoring Pulse oximeter (continuous) Auto BP (ideal) CO2 device (ET confirmation device) Rapid Sequence Induction
- 25. Pre-oxygenation: Functional residual capacity Oxygen 6-10 l/min via snug mask Three minutes ideal if spontaneous breathing In “crash”, may use RSI agents and O2 by BVM with mandatory Sellick Rapid Sequence Induction
- 26. Pre-medication: Atropine All children under 12 years Adults with heart rate 100 or less *** Second dose of Succinylcholine Dosage: 0.5 to 1.0 mg adult Dosage 0.01 to 0.02 mg child (1 mg max) Give ideally 2-3 minutes prior to intubation Rapid Sequence Induction
- 27. Pre-medication (cont.) Lidocaine Decrease adrenergic and physiologic response to laryngoscopy and intubation Decreases ICP response Mucosal anesthesia Dosage: 1.0-1.5 mg/kg IV 2-5 minutes prior to intubation Rapid Sequence Induction
- 28. Sedation Agents Selection of agent(s) perfusion state presence of head injury clinical diagnosis Paramedic drug box Rapid Sequence Induction Paralytics Have No Sedative Quality
- 29. Selection of Sedative (cont.) Benzodiazepines Amnestic and at high dose, anesthetic Little cardiovascular depression Diazepam Slow onset/longer lasting 3-5 mg IV (adult) 0.2 to 0.4 mg/kg (kids) titrate Rapid Sequence Induction
- 30. Benzodiazepines (cont.) Midazolam Rapid onset Potent amnestic Moderate decrease in ICP 1-3 mg IV (adult) 0.1 mg.Kg titrated in kids Rapid Sequence Induction
- 31. Selection of Sedative (cont.) Narcotics Potent analgesics/sedatives Rapid onset w/ brief duration Effect can be reversed! Morphine 2-20 mg IV May cause refractory bradycardia/hypotension Rapid Sequence Induction
- 32. Selection of Sedative (cont.) Butyrophenones: Useful as anxiolytics May cause EPS Minimal cardiac effect Haloperidol Potentiates effect of narcotics EPS more common 2.5-5.0 mg IV/IM Rapid Sequence Induction
- 33. Rapid Sequence Induction Selection of Sedative (cont.) Etomidate Non-barbiturate hypnotic Rapid onset of action, short duration Does not blunt sympathetic response to intubation Dose: 0.3 mg/kg IV 20 mg maximum dose Not indicated for peds <10 years
- 34. Induction Agents ACh binds to post synaptic receptors causing depolarization … Contraction of muscle ACh removed by acetylcholinesterase and by diffusion …. Relaxation of muscle Neuromuscular Junction Dailey; The airway: emergency management
- 35. Mechanism of action: Nondepolarizers Competitive Block ACh receptors … paralysis Depolarizers Noncompetitive Persistent stimulation …fasciculations Unresponsiveness to ACh….Paralysis Induction Agents
- 36. Dailey; The airway: emergency management
- 37. Depolarizing Succinylcholine Vagal effects Excessive bronchial secretions Negative inotropic and chronotropic, esp. with repeated dose and in children Fasciculations (amelioration) Malignant hyperthermia? Complete paralysis w/in 30-45 sec. Lasting 4-6 min 1.5 mg/kg IV Induction Agents
- 38. Succinylcholine (cont.) Metabolized via Cholinesterase 0.3% defective enzyme Contraindications Absolute - none Hyperkalemia Renal failure Crush injury Burns Myotonia Paraplegia Induction Agents
- 39. Non-depolarizing Vecuronium Minimal cardiovascular effect Long duration of action (may exceed 90 mins) Shorter onset than Pancuronium 0.1 mg/kg Induction Agents
- 40. RAPID SEQUENCE INTUBATION INDICATIONS : Need for immediate intubation assumed with failed intubation attempt PROCEDURE: Protect C-Spine prn O 2 100% w/ BVM assist (hyperventilate pt. if possible) Suction prn IV w/ balanced salt solution; EKG *** Cricothyroidotomy equipment available *** Lidocaine 1 mg/kg IV Atropine 0 5 mg IV adults w/ HR <80 (0 01 mg/kg IV All kids <12 ) Etomidate 0 3 mg/kg max 20 mg-5 mg IV Adults and peds >10 yr for sedation. Succinylcholine 1 5 mg/kg IV bolus *** Sellick until intubation successful and ETT cuff inflated *** Perform intubation (once fasciculations stop) If relaxation inadequate in 60-120 secs, repeat Succinylcholine 1 5 mg/kg IV reattempt intubation Confirm placement by auscultation, capnography Secure ETT Ventilate w/ BVM & 100% O 2 Maintain EtCO 2 35-40 mm/Hg If further paralysis required: Vecuronium 0 1 mg/kg Versed 2 5-5 mg IV for sedation (peds 0 1mg/kg)
- 44. Digital Tactile Intubation Eschmann Lighted stylette Fiberscope BURP Intubation Tricks
- 45. SURGICAL AIRWAYS Cricothyrotomy Indications (Identified need for intubation) Maxillofacial trauma Oropharyngeal obstruction Edema FBAO Mass Lesion Cancer Unsuccessful oral/nasal tracheal Difficult anatomy Massive hemorrhage/regurgitation
- 46. SURGICAL AIRWAYS Cricothyrotomy (cont..) Contraindications: Age <10-12 Laryngeal crush injury Laryngeal tumor/stricture Tracheal transsection subglottic stenosis Expanding hematoma Coagulopathy Unfamiliar w/ procedure
- 47. SURGICAL AIRWAYS Anatomy: Thyroid cartilage Cricoid ring Cricoid cartilage Thyroid gland Trachea Major vessels
- 48. SURGICAL AIRWAYS Netter; Atlas of Human Anatomy
- 49. SURGICAL AIRWAYS Procedure: Identify thyroid cartilage Cricothyroid membrane Vertical incision through skin Prep prior Incise membrane Open incision Dilator/tracheal hook Insert ETT/Trach tube Ventilate patient
- 50. SURGICAL AIRWAYS Complications: Incorrect placement Long execution time Hemorrhage Passage sub Q Plugging Pneumomediastinum Aspiration etc.
- 51. SURGICAL AIRWAYS Anderson; Grant’s Atlas of Anatomy
- 52. SURGICAL AIRWAYS Retrograde Tracheal Intubation (RTI): Indications Abnormal anatomy Pt. W/ epiglottitis Severe kyphosis Cervical spondylosis Trauma Reasonable alternative to Surg and Needle Crike
- 53. SURGICAL AIRWAYS RTI (cont...): Contraindications Trismus (w/o paralytic) Coagulopathy Enlarged thyroid Procedure: Supplemental O 2 Catheter over needle into CTM Insert guidewire through catheter Visualize guidewire and pass tube
- 54. Dailey; The airway: emergency management
- 55. SURGICAL AIRWAYS Needle Cricothyrotomy Indications Same as for any surgical airway Considered safer and quicker than surgical crike Will not compromise c-spine in trauma pt. Contraindications Total obstruction at or near the cords Complications Misdirection Puncture tracheal wall Local cord damage Does not prevent aspiration!
- 56. SURGICAL AIRWAYS Needle Cricothyrotomy Procedure Supplemental O 2 Catheter over needle into CTM (at least 14 ga) Attach to high pressure O 2 source (50psi) Ventilate using valve or “interrupter type device