CAP Module 4 DIFFICULT AIRWAY MANAGEMENT CAP Module

CAP – Module 4 DIFFICULT AIRWAY MANAGEMENT CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

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_April 2015)

A&P Review �Upper airway �Nasopharynx �Oropharynx �Laryngopharynx �Larynx CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

A&P Review �Glottic structures �Glottic opening �Vocal cords �Cuneiform cartilage �Corniculate cartilage Together make up the Arytenoid Cartilage CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

A&P Review �Laryngeal landmarks �Thyroid cartilage �Cricothyroid membrane �Cricoid membrane �Thyroid gland CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

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_April 2015)

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_April 2015)

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_April 2015)

External look CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

3 -3 -2 Rule CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Mallampati Score �Mallampati, Cormack and Lehane scores CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Obstruction �Foreign body �Trauma �Swelling �Esophageal spasms �Growth �Infection CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

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_April 2015)

Neck Mobility �Arthritis �Spinal immobilization �Location of patient Entrapment – discuss possibilities CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Decision Making �Question One �Is Ventilation Adequate or Inadequate? �Question Two �Is the Airway Normal or Disrupted? CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Decision Making: Ventilation Adequate Sa. O 2 > 90% Also note respiratory rate, effort Et. CO 2 spot reading may be unhelpful (e. g. CO 2 retainers) Inadequate Sa. O 2 < 90% Note baseline may be below 90% Also note respiratory rate, effort CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Decision Making: Airway Normal Airway Disrupted Airway �Still identified as technically difficult �Anatomy intact �Examples: �Still identified as technically difficult �Abnormal anatomy �Examples: � Obesity � Trauma/burn � Anterior glottis � Infection � Small mouth � Hematoma � Cancer � Foreign body CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

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_April 2015)

Combitube Protocol PROC-120 CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Eschmann Catheter Protocol PROC-100 CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Surgical Cricothyrotomy Protocol PROC-290 CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

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_April 2015)

Difficult Airway Algorithm Call for additional assistance Able to BVM Pt w/adjuncts No Move to failed airway algorithm Yes RSI completed Yes Follow post intubation protocol No Try with a different blade/partner tries RSI completed Yes No Use Eschmann Catheter Yes RSI Completed No Move to failed airway algorithm CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

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, nonsurgical (e. g. “quicktrach”) is not CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Failed Airway Algorithm Failed Airway criteria met Able to BVM patient? Call for assistance No Cricothyrotomy Yes Consider Combitube Time allows and successful? No Yes Able to maintain Sp. O 2>90% No Yes Arrange for definitive Airway Management CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)

Airway Management Questions? CAP Module 4 - Difficult Airway Management (GHEMS_April 2015)