by: parrish t. eilers, md lsu emergency medicine

AIRWAYBASICS

By: Parrish T. Eilers, MDLSU Emergency Medicine

Airways

The Emergency Medicine Physician should be proficient in the assessment and management of all types of patient airways, regardless of age, gender, or level of difficulty.

Goals

By the end of this lecture, students should able to:

A) Properly assess a patient’s airway. B) Discuss techniques for properly

ventilating a patient. C) Identify tools and proper technique

needed for intubating a patient. D) Discuss RSI

Why do I need to intubate this patient?

1) Failure to oxygenate or ventilate

2) Unable to protect their airway

3) Expected Clinical Course

Airway Assessment

The first step needed before intubating any patient, should be to assess their airway.

Steps needed for airway assessment, should start with can I properly ventilate this patient

Ventilation vs Intubation

Ventilation is the exchange of air between the lungs and the environment, including inhalation and exhalation.

Endotracheal Intubation is the placement of an airway into the trachea for airway maintenance.

Ventilation

Requirements for bag mask ventilation: Need to have an open airway Need to have a proper mask seal between the

patient and your mask

MOANS

Evaluating for bag mask ventilation difficulty

MOANS M: Mask Seal O: Obesity A: Age(>50 years) N: Neck Mobility S: Stiff(ie lung stiffness)

Bag Mask Ventilation

Patients should ideally be supine in the “sniffing” position

Mask should cover the nose and mouth of the patient

Bring the patient’s face UP to the mask, by holding onto the mandible, not the soft tissue under the chin. Don’t push the mask down on a patient’s face.

Can use oral or nasal pharyngeal airways to assist with bagging

Two rescuer technique is best

Hard to Bag?

LEMON

Evaluating for Difficult Intubation

LEMON L: Look for any anatomy distortion E: Evaluate using 3-3-2 method M: Mallampati score O: Obstruction, any signs of N: Neck Mobility

Mallampati Score

Macintosh vs Miller Blades

Airway Anatomy

Intubation

After assessing the airway, begin by looking down at the patient’s face from above the head. Then you gently scissor open the patient’s mouth, with your right hand. With the laryngoscopic blade in your left hand, insert it into the right side of your patient’s mouth and advance it along the tongue. If using a MAC blade, advance to the base of the tongue or the vallecula and sweep the tongue to the left. While doing this you’re also pulling your blade towards their feet. If using the Miller blade, then advance to the epiglottis and place the tip of your blade on the epiglottis. Then you sweep the tongue to the left and pull your blade towards your patient’s feet, lifting the epiglottis. Your Goal is just below the epiglottis.

The prize

Or This

Rapid Sequence IntubationRSI

1) Preparation 2) Preoxygenation 3) Pretreatment 4) Paralysis with Sedation 5) Protection of Airway(Sellick manuver) 6) Pass the Tube( with Confirmation) 7) Postintubation Management

Preparation

Preparation is key to intubating your patient and should begin before your patient even arrives at the hospital.

Tools Needed for Intubation

Oxygen with Bag/Mask and NRB Suction Endotracheal tubes Oral and Nasal Airways Syringe Laryngoscope Blade with working Handle Bougie, LMA Mask with Face shield and Gloves Surgical airway Equipment

Preoxygenation

All patient’s should be pre-oxygenated with 100% O2 by NRB or Bag/Mask for 2 minutes prior to intubation, even if they’re sats are 100% by NC O2.

Because you want to blow off as much Nitrogen as possible and saturate your patient’s alveoli with oxygen.

Pretreatment

Give drugs to aid with the physiologic responses of intubation Lidocaine--------blunts bronchospasm and the

reflex response Opioid(Fentanyl)---------blunts reflex response Atropine--------to avoid bradycardia in kids

receiving Succinylcholine Depolarizing Agent----- to attempt to prevent

fasciculations

Paralysis with Sedation

Give your RSI drugs, sedation first and then your paralytic. Usually pushed one right behind the other. Common Paralytics

Succinylcholine Rocuronium

Common Sedatives Etomidate Ketamine Ativan Versed

Protection

The airway is usually protected by using the Sellick maneuver or cricoid pressure, during paralysis, intubation, and confirmation of tube placement. The cricoid ring is compressed with the assistant’s index finger and thumb.

Passage of the Tube

The tube is placed by direct visualization of the tube passing through the vocal cords. Inserted to a distance of about 3 times the tube size. Usually about 24cm in adult males and about 21 in adult females. Verify tube placement by watching the tube go through the cords, CO2 detector, auscultation of bilateral breath sounds, and CXR.

Postintubation Mgmt

Don’t forget long term sedation and vent settings. Also don’t forget to check your postintubation CXR.