9/20/18. Ear To Sternal Notch. Primary Methods to Rescue & Prevent Failed Intubation. Ear to Sternal Notch Position

Transcription

1 Primary Methods to Rescue & Prevent Failed Intubation Communicating and Working with a Knowledgeable Assistant External Laryngeal Manipulation Bimanual Larynogscopy Head-Elevated Larynogscopy Position (HELP) Bougie-Assisted Intubation Difficult & Failed Intubaiton ELM versus BURP Ear to Sternal Notch Position Ear To Sternal Notch 1

2 Troop Elevation Pillow Obese position without stacking Axis Alignment with Troop Elevation Pillow View from head with stacking Bougie-Assisted Intubation 2

3 INDICATORS OF TRACHEAL PLACEMENT INCLUDE: 1. TRACHEAL CLICKING - The tactile sensation that is created as the distal tip moves over the tracheal rings 2. HOLD UP - The gum-elastic bougie will not hold up if it is placed in the esophagus. Cormack & Lehane Grade III Bougie Essentials EPIGLOTIS Leave laryngoscope in place during ETT insertion. Rotate ETT counter clockwise 90 degrees. INTERARYTENOID NOTCH 3

4 Arytenoid Collision Cormack & Lehane Grade III EPIGLOTIS INTERARYTENOID NOTCH Airway Exchange Catheters Airway Exchange Catheter LMA Optical Stylet Intubaiton 4

5 LMA-Fastrach CHANDY S MANUEVER Intubating LMA - Fastrach S The LMA-Fastrach L A SLAM National Conference 2004 Fort Worth, TX Friday 24th April 2004 M Re-thinking the Gold Standard in Pre-hospital Trauma Care by: Dr Andy Mason MB BS MRCS LRCP (Immediate Care Physician Bury St Edmunds, UK) INTUBATING LMA (ILMA) or LMA-Fastrach The Single-use LMA-Fastrach Anatomically-curved stainless steel airway tube Handle Cuff inflation line Silicone coating on airway tube Epiglottic elevating bar Silicone cuff Cuff inflation valve (with pilot balloon) 5

6 Fastrach in the Operating Room: Awake Spontaneous Ventilations Fastrach in Obtunded Patient GCS = 3 6

7 Airway Management for C-Spine Injury Overview of C-Spine Injury 10,000 New Cases Annually in U.S. Majority are a result of MVC. Median Age at Injury is 25. More Males than Females (4:1 Ratio). Annual cost to society estimated at $5 Billion. Cervical Spine Injury and Major Trauma Major Trauma is associated with a 2% to 6% risk of cervical spine injury. No imaging modality is accurate 100% of the time. MIAS is an effective technique to prevent cervical spine injury. Symptoms & Signs of C-Spine Injury Neck pain, tenderness, deformity Paresthesias, tingling Diaphragmatic breathing Hypoventilation Neurogenic shock (loss of vasomotor tone and sympathetic innervation to heart) Absent rectal tone Sensory and motor abnormality (inability to perceive pain below level of lesion may mask serious injury elsewhere) Airway Management: Indications for T.I. Requirement for surgery and G.A. Respiratory Distress Airway Protection Shock Tracheal Toilet Airway Management for C-Spine Injury Head & Neck are immobilized during all airway maneuvers with suspicion of injury. Supplemental oxygen is provided. Oxygenation & Ventilation are ensured prior to T.I. by providing basic airway maneuvers. 7

8 Airway Management: The only clear guideline that exists is stabilization and immobilization of the head and neck! MIAS Rigid cervical collar with tape and sandbags Surgical Immobilization Tongs Halo-vest Importance of MIAS New neurologic deficits occur 7.5 times more frequently with an unrecognized injury, and Up to 10% of cervical spine injured patients will suffer a new neurologic deficit if not immobilized. Manual In-Line Axial Stabilization Applied by holding the sides of the neck and the mastoid processes and exerting downward pressure, thus preventing movement of the head and neck during intubation. Challenges Imposed by MIAS Lehane and Cormack Laryngoscopic Grades Results in higher incidence of difficulty. Cannot optimally align airway axes. One study showed that MIAS resulted in 22% incidence of grade III view.* Reduced the optimal view of the larynx in 45% of patients.* *Nolan, et al. Orotracheal intubation in patients with potential cervical spine injuries: an indication for the gum elastic bougie. Anaesthesia 1993: 48:

9 Airway Management: Urgent Cases Coexisting Trauma Shock Immediate need for surgery Decreased LOC and unprotected airway Respiratory Distress Airway Mangement: Urgent & Emergency Cases Conventional laryngoscopy Gum Elastic Bougie With conventional laryngosocpy With flex-tip blade Video Laryngoscopy LMA Assisted Flexible Fiberscope Urgent Cases: Improving the Laryngeal View- BURP BURP = backward upward rightward pressure External laryngeal Manipulation (ELM) can convert grade VI to grade III; grade III to grade II. Adding the Gum Elastic Bougie is synergistic. Urgent Cases: Intubation Technique MIAS should be applied before removing rigid cervical collar. Impedes mouth opening Impedes performance of CP and ELM Anesthesia induction choices: STP, Etomidate, Ketamine, or propofol Induction doses may need to be reduced to prevent hypotension and myocardial depression in patients with high spinal lesions. Summary Major trauma is associated with a 2% to 6% incidence of c-spine injury. No imaging modality is 100% reliable. MIAS is effective & mandatory but increases the incidence grade III and VI views. Anterior portion of rigid collar should be removed only after MIAS in place and reapplied after TI. No prospective study has shown that any intubation technique is unsafe if MIAS is used. Awake intubation techniques allow for post intubation neurologic eval but require good airway anesthesia and conscious sedation. ELM, G.E.B., VL: all faciliate TI after GA inducation with RSI. Video laryngoscopy: See What You ve Been Missing! 9

10 Current video laryngoscopes Glidescope McGrath CoPilot VL Airtraq Karl Storz VL Intubation is sometimes difficult Curve of Video laryngoscope Blade = Alignment of Axes Video - Laryngoscopy Camera integrated in handle Cables to cold light source + imaging processing module Video view -angle 60 Light-fibres surround viewfibres Standard viewangle 10 Video laryngoscopes: Blade Type- Non-channeled Videolaryngoscopes: Non-channeled Blade Type McGrath Glidescope Glidescope (Verathon, Bothell WA) Lo Pro Adult Ranger Pediatric Neonatal Cobalt McGrath (Aircraft Medical, Edinburgh Scotland) Karl Storz (Culver City, CA) Video Macintosh System 10

11 Glidescope GlideScope Video Intubation System High resolution Video camera Imbedded w/i Laryngoscope blade Displayed on 7 LCD Monitor LED Light Source Adult Standard RANGER Pediatric Neonatal 60 degree angle High resolution digital camera LCD light source Monitor with video output GlideScope uses Videolaryngoscopy Difficult airway/failed intubation Limited cervical spine movement Rapid sequence induction Visualization during ETT changes GlideScope Easy to learn, the skill is intuitive and similar to direct laryngoscopy Allows others to see the view and assist the laryngoscopist Frequently improves the laryngoscopy view Requires some degree of mouth opening for manipulation Practice is needed to improve hand-eye coordination McGrath Video Laryngoscope Video-based system Camera in stick Small LCD display Disposable blade Powered by one AA battery 11

12 Limitations No video recording No pediatric/ neonatal blade (can be used in patients down to 8 kg) Occasional fogging use antifog routinely with all VLs for best results McGrath vs Glidescope Key Differences v Mouth Opening Ø 14 mm GVL Ø McGrath Disarticulating/ 12.5 mm v Durability Ø GVL Blade easily breakable Ø GVL cables disconnect Ø McGrath sturdy Ø McGrath Blade Disposable v Stylet in ETT Ø Very useful in both v Power Source/Mobility Ø Standard GVL: Plug in Ø Ranger GVL- Battery Ø McGrath- Single AA Battery v Field of View Ø Equal (60 degrees) v Location of Screen Ø Midline McGrath Ø Side GVL v Blade Length Ø McGrath adjustable Ø GVL: Neonatal - Adult Tips for Successful Video-Laryngoscopy Always use stylet in ETT vcurve similar to hockey-stick Insert blade midline Drop of Antifog or Warming Blade/Camera Stick useful for McGrath Advance ETT under Blade vwithdraw stylet when tip of ETT thru VC vif needed rotate ETT to aid insertion. Tips for Successful Video-Laryngoscopy Head Position: v Sniffing if possible v Neutral also feasible Curvature of Blade aligns axes. Open mouth widely to accommodate blade v Glidescope v Minimum 14 mm needed for insertion McGrath Blade is Disarticulating v Maximum width of device = 12.5 mm v Blade can be inserted like a tongue depressor with limited mouth opening Videolaryngoscopes: Blade Type - Channeled Pentax AWS AirTraq Optical Laryngoscope Disposable optical laryngoscope Magnified angular view of larynx No movement of neck required Clip-on video system 12

13 Airtraq Insertion Airtraq Insertion-I.D. Airway Structures Airtraq Removing Airtraq Hold ETT securely Rotate Airtraq and slide from mouth Do not pull straight out or upright Airtraq VL 13

14 AWS King Vision VL Karl Storz Video Laryngoscope Conclusions Evaluate the airway Plan for any difficulty Learn new airway techniques (but practice on easy airways) Do not forget the art of mask ventilation Unanticipated Difficult Airway Call for help! Mask ventilate Consider supraglottic device if ventilation is difficult Awaken patient and perform topicalized intubation if necessary Try: Video-laryngoscope ILMA Fiberoptic with LMA classic 14

15 Conclusions Future of airway management Easy to learn and to teach Many applications Must be used carefully Hope for the Best! Prepare for the WORST!!! Have a backup plan!!!! 15