Advanced Airway: Lynn K. Wittwer, MD, MPD Clark County EMS

Advanced Airway
Lynn K. Wittwer, MD, MPD

Clark County EMS
Advanced Airway
Anatomic Considerations
Rapid Sequence induction
Induction Agents
Intubation tricks
Indications for Definitive Airway
Need for Airway Protection Need for Ventilation
Unconscious Apnea
Neuromuscular Paralysis
Unconscious
Severe Maxillofacial fx’s Inadequate Respiratory Effort’
Tachypneal
Hypoxia
Hypercarbia
Cyanosis
Risk for aspiration Severe closed head injury with need
Bleeding for hyperventilation
Vomiting
Risk for obstruction
Neck hematoma
Laryngeal, tracheal injury/burn
Stridor
ANATOMIC CONSIDERATIONS FOR
INTUBATION
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
INTUBATION (cont.)
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
Netter; Atlas of Human Anatomy
INTUBATION (cont.)
Trachea
– 12-15 cm. Adult
– 4 cm. Newborn
– right mainstem
larger,shorter and
less angle Anderson; Grant’s Atlas of Anatomy
ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)
Anderson; Grant’s Atlas of Anatomy
OTHER CONSIDERATIONS FOR
INTUBATION (cont.)
– 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.)
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
Correct Placement for intubation (b)
Patient in correct position for intubation (sniffing position)
Incorrect airway position (hyperflexed)
Rapid Sequence Induction
Indications
– Ventilatory failure
– Airway maintenance/protection
– Treatment and evaluation
neuro resuscitation(hyperventilate)
shock
drug overdose
Contraindications
– Cardiac arrest
– Adequate ventilation
– Deeply comatose patient, absent tone
– Post-intubation sedation
Contraindications
(cont.)
– Intubation likely
unsuccessful
Partially obstructed
airway
Severe facial Whitten; Anyone Can Intubate
abnormality(trauma,
etc.)
McIntyre; The difficult tracheal intubation
Maintain adequate oxygenation

Airway protection
– Prevent regurgitation, aspiration
Obtund adverse cardiovascular and ICP
response to intubation
Better early than late
Hypoxemia and acidosis effects
Treatment Algorithm
– Preparation
– Pre-oxygenation( functional reserve capacity)
– Pre-medication
– Sedation
– Cricoid pressure
– Paralysis
– Intubation
DO NO HARM!
TAKE AWAY NOTHING FROM

THE PATIENT YOU CANNOT
REPLACE
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
Airway Evaluation
Problem Airway
epiglottis Vocal cords

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
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)
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
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
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
Paralytics Have No Sedative Quality
Sedation Agents
– Selection of agent(s)
perfusion state
presence of head injury
clinical diagnosis
Paramedic drug box
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
Benzodiazepines (cont.)
Midazolam
– Rapid onset
– Potent amnestic
– Moderate decrease in ICP
– 1-3 mg IV (adult)
– 0.1 mg.Kg titrated in kids
– Narcotics
Potent analgesics/sedatives
Rapid onset w/ brief duration
Effect can be reversed!
– Morphine
2-20 mg IV
May cause refractory bradycardia/hypotension
– 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
– 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
Induction Agents
Neuromuscular Junction
ACh binds to post
synaptic receptors
causing depolarization …
Contraction of muscle
Dailey; The airway: emergency management

ACh removed by
acetylcholinesterase and
by diffusion ….
Relaxation of muscle
Induction Agents
Mechanism of action:
– Nondepolarizers
Competitive
Block ACh receptors … paralysis
– Depolarizers
Noncompetitive
Persistent stimulation …fasciculations
Unresponsiveness to ACh….Paralysis
Induction Agents
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
– Succinylcholine (cont.)
Metabolized via Cholinesterase
– 0.3% defective enzyme
Contraindications
– Absolute - none
– Hyperkalemia
Renal failure
Crush injury
Burns
Myotonia
Paraplegia
Induction Agents
•Non-depolarizing
–Vecuronium
•Minimal cardiovascular effect
•Long duration of action (may exceed 90 mins)
•Shorter onset than Pancuronium
•0.1 mg/kg
RAPID SEQUENCE INTUBATION
INDICATIONS:
Need for immediate intubation assumed with failed intubation attempt
PROCEDURE:
Protect C-Spine prn
O2 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% O2
Maintain EtCO2 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)
Airway Management
Airway Management
Airway Management
Intubation Tricks
Digital
Tactile
Intubation
Eschmann
Lighted
stylette
Fiberscope
BURP
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
SURGICAL AIRWAYS
•Cricothyrotomy (cont..)
–Contraindications:
–Age <10-12
–Laryngeal crush injury
–Laryngeal tumor/stricture
–Tracheal transsection
–subglottic stenosis
–Expanding hematoma
–Coagulopathy
–Unfamiliar w/ procedure
SURGICAL AIRWAYS
Anatomy:
– Thyroid cartilage
– Cricoid ring
– Cricoid cartilage
– Thyroid gland
– Trachea
– Major vessels
SURGICAL AIRWAYS
Netter; Atlas of Human Anatomy

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
SURGICAL AIRWAYS
Complications:
– Incorrect placement
– Long execution time
– Hemorrhage
– Passage sub Q
– Plugging
– Pneumomediastinum
– Aspiration
– etc.
Anderson; Grant’s Atlas of Anatomy
SURGICAL AIRWAYS
SURGICAL AIRWAYS
Retrograde Tracheal Intubation (RTI):
– Indications
Abnormal anatomy
– Pt. W/ epiglottitis
– Severe kyphosis
– Cervical spondylosis
Trauma
Reasonable alternative to Surg and Needle
Crike
SURGICAL AIRWAYS
RTI (cont...):
– Contraindications
Trismus (w/o paralytic)
Coagulopathy
Enlarged thyroid
– Procedure:
Supplemental O2
Catheter over needle into CTM
Insert guidewire through catheter
Visualize guidewire and pass tube
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!
SURGICAL AIRWAYS
Needle Cricothyrotomy
– Procedure
Supplemental O2
Catheter over needle into CTM (at least 14 ga)
Attach to high pressure O2 source (50psi)
Ventilate using valve or “interrupter type device

Advanced Airway: Lynn K. Wittwer, MD, MPD Clark County EMS

Uploaded by

Copyright:

Available Formats

Advanced Airway: Lynn K. Wittwer, MD, MPD Clark County EMS

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Advanced Airway: Lynn K. Wittwer, MD, MPD Clark County EMS

Uploaded by

Copyright:

Available Formats

Advanced Airway

Lynn K. Wittwer, MD, MPD

Maintain adequate oxygenation

TAKE AWAY NOTHING FROM

Anticipate the difficulties

epiglottis Vocal cords

Paralytics Have No Sedative Quality

Selection of Sedative (cont.)

Dailey; The airway: emergency management

Netter; Atlas of Human Anatomy

You might also like