Management of the Emergent Airway Josh Bucher MD

Management of the Emergent Airway Josh Bucher, MD

Airway Management Objectives ● Appreciate the pertinent airway anatomy ● To ● Perform basic airway maneuvers ● Perform surgical cricothyroidotomy ● Advanced airway techniques ● Some slides are from Reuben Strayer’s Lecture from Mount Sinai RWJ EM

Airway Management Disclosures • I will say almost anything if you pay me to RWJ EM

Airway Management What is the problem here? RWJ EM http: //vimeo. com/56704003

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Airway Management Ventilation not Intubation RWJ EM

Airway Management RWJ EM

Airway Management http: //www. acep. org/Clinical--Practice-Management/Focus-On--Bag-Valve-Mask-Ventilation/ RWJ EM

Airway Management RWJ EM http: //www. outsidetheprotocols. com/2 012_06_01_archive. html

Airway Management RWJ EM

Airway Management Can other people ventilate? • • • Nursing Respiratory CCTs Medical Student Pharmacy Student Pre-med volunteer RWJ EM

Airway Management Basic Airway Maneuvers • • • Head tilt-chin lift Jaw thrust Oropharyngeal Nasopharyngeal airways Positioning RWJ EM

Airway Management RWJ EM From merck manual

Airway Management RWJ EM

Airway Management Jaw-Thrust Maneuver RWJ EM http: //circ. ahajournals. org/content/102/suppl_1/I-22. figures-only

Airway Management RWJ EM

Airway Management Oropharyngeal Airway http: //www. simulaids. com/sb 35197. htm http: //www. drgreen. co. uk/teaching%20 topics/ Chapter%209%20 Airway%20 dri ps%20 and%20 ECG. htm RWJ EM

Airway Management Nasopharyngeal Airway http: //www. aic. cuhk. edu. hk/web 8/Nasopharyngeal%20 airway. htm RWJ EM

Airway Management Sniffing Position http: //www. outsidetheprotocols. com/2012_06_01_archive. html RWJ EM

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Airway Management Endotracheal Intubation RWJ EM

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Airway Management Can we predict difficulty with ventilation? RWJ EM http: //crashingpatient. com/wp-content/images/part 1/mandible. jpg

Airway Management The mandibular protrusion test may be an essential element of the airway examination. (Anesthesiology 105(5), November 2006, pp 885891) • • • Beard Obesity No teeth > 55 yrs of age Snoring Mallampati III or IV Limited jaw protrusion Thyromental distance < 6 cm Limited neck mobility RWJ EM

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Airway Management Awake? Who? When? RWJ EM

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Airway Management RWJ EM (Lee BJ, Kang JM, Kim DO (2007) Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth 99: 581� 586)

Airway Management RWJ EM

Airway Management http: //crashingpatient. com/resuscitation/airw ay/airway. htm/ RWJ EM

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Airway Management WHAT ABOUT CRICOID PRESSURE? ? ? RWJ EM

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Airway Management RWJ EM The AIRWAY • CAM Pocket Guide to Intubation Richard M. Levitan, MD

Airway Management RWJ EM The AIRWAY • CAM Pocket Guide to Intubation Richard M. Levitan, MD

Airway Management RWJ EM

Airway Management RWJ EM Straight to cuff with 35 degree bend probably is best (ACADEMIC EMERGENCY MEDICINE 2006; 13: 1255� 1258

Airway Management RWJ EM http: //crashingpatient. com/wpcontent/images/part 1/mallamclehan e. jpg

Airway Management Contraindications to roc? RWJ EM

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Airway Management RWJ EM Weingart S. Preoxygenation and Prevention of Desaturation During Emergency Airway Management

Airway Management PREOXYGENATION? RWJ EM

Airway Management RWJ EM http: //crashingpatient. com/resuscitation/airway. htm/

Airway Management RWJ EM

Airway Management Is NRB the best? • Patient breathing adequately? – NRB at 15 lpm? – 70 – 80% Much longer time to desat in the obese if you preoxygenate in sitting position (British Journal of Anaesthesia 2005 95(5): 706709) RWJ EM

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Airway Management = DON’T BAG (MOSTLY) RWJ EM

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Airway Management RWJ EM

Airway Management Can’t Intubate/Can’t Ventilate or three failed attempts Best Attempt Definition: • Performed by a reasonably experienced laryngoscopist • No significant muscle tone • Use of optimal sniff position • Use of external laryngeal manipulation • One change in length of blade • One change in type of blade RWJ EM http: //crashingpatient. com/resuscitation/airway. htm/

Airway Management • RWJ EM http: //www. rushemergencymedi cine. com/2011_site/index. php/l ectures/show_lecture/airway_a dvanced

Airway Management RWJ EM [Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: a 10 -year experience at a major adult trauma referral center. Anesth Analg. 2009 Sep; 109(3): 86672. ]

Airway Management Something goes wrong… 1. 2. 3. 4. RWJ EM Displaced tube Obstruction Pneumothorax Equipment

Airway Management RWJ EM The AIRWAY • CAM Pocket Guide to Intubation Richard M. Levitan, MD

Airway Management Digital Intubation RWJ EM

Airway Management LMA RWJ EM

Airway Management ILMA RWJ EM

Airway Management Cricothyrotomy RWJ EM

Airway Management What do you need? RWJ EM

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Airway Management https: //www. youtube. com/watch? v=I 6 wod. B 2 S 0 uc RWJ EM

Airway Management Joshua. T. Bucher@gmail. com RWJ EM