9/20/18. Airway Assessment & Evaluation. Winner PGA 2003: Best Exhibit for Clinical Application

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1 The SLAM Universal Emergency Airway Flowchart SLAM Rescue Airway Flowchart James M. Rich, CRNA, MA Department of Anesthesiology & Pain Management Baylor University Medical Center, Dallas, TX A thorough understanding of the flowchart is necessary prior to its use. Algorithms by their very nature cannot be allencompassing and need to be interpreted, modified, and applied according to individual patient assessment and good clinical judgment 2 Airway Assessment & Evaluation The Devil is in the Details!!! Ross Perot 3 Winner PGA 2003: Best Exhibit for Clinical Application 1

2 SLAM Flowchart Fills a dual role as both an emergency and difficult airway algorithm. Manages difficult airway situations through practical methods to modify failed intubation attempts, While providing the emergency airway practitioners with clinical guidance on: 1. When tracheal intubation is appropriate, 2. When to stop attempting tracheal intubation, or 3. When to undertake rescue ventilation. SLAM Universal Emergency Airway Flowchart Four Clinical Care Pathways Decision Points: Determines the direction of the flow based upon a yes or no answer. 2

3 Action Blocks: Tells you when to proceed with a therapeutic intervention. ücall for help, üassess patient, üobserve üintubate, üventilate, ümodify technique, üswitch technique, üetc. Explanatory Blocks: üprovides explanation ügives options (T.I. & R.V.) Consideration Borders: üdashed Lines üreminder of a clinical consideration Critical or Danger Blocks: ücrash airway ücritical Airway Event ülike the 3-second zone in basketball stay here and you will lose the patient, üalways leads to Rescue Ventilation Pathway Crash airway: Describes patients who have severe acute respiratory failure and typically 1) exhibit reduced responsiveness or are unresponsive; 2) have a respiratory rate of <10 or >30 breaths per minute; and 3) have severely depleted oxygen levels. Such patients are usually close to death and require either rapid tracheal intubation or immediate rescue ventilation. Critical airway event: Indicated by 1) any CMVCI situation; 2) three or more failed intubation attempts or attempted intubation for >10 minutes by an experienced laryngoscopist; or 3) sustained hypoxemia that is refractory to positive-pressure ventilation with 100% O2. SAFE BLOCKS: üpost-intubation Management üt.i. is confirmed ürescue Ventilation is effective Recognition and Management of the Crash Airway 3

4 Why choose an SpO 2 of 92%? Why choose an SpO 2 of 92%? Why choose an SpO 2 of 92%? Rescue Ventilation & Cricothyrotomy Pathways Rescue Ventilation with any FDA Approved SAD. Cric can be TTJV, PDC or Surgical Cricothyrotomy 4

5 What is Rescue Ventilation Administration of 100% oxygen and positive pressure ventilation, preferably via an FDA approved alternative airway device: Combitube, Easytube LMA, King LT, Cobra PLA, Easytube Critical Airway Event Thresholds for Switching to R.V. CMVCI Refractory Hypoxemia PU 92 Failed Intubation 3 times or T.I. attempted for > 10 minutes. OBSERVE, ASSESS, DECIDE!!!! BEWARE OF CLOSED-SPACE RESCUE SITUATIONS. WHAT OR WHO IS YOUR WEAKEST LINK? ASSESS THE AIRWAY AS THOROUGHLY AS POSSIBLE EASIER TO STAY OUT OF TROUBLE THAN TO GET INTO TROUBLE DON T BE A COWBOY CONSIDER RESCUE VENTILATION FIRST (DARV). 5

6 Oxygenation Ventilation Pathway Oxygenation Ventilation Pathway ç YES ç YES ç NO Oxygenation Ventilation Pathway Non-rebreathing Mask with OPA/NPA PPMV with OPA/NPA Supraglottic Airway Device Difficult Mask Ventilation: FACES F-Facial Hair A-Age > 55 C-Chubby BMI>26 E-Edentulous S-Snoring 6

7 No RSI Pathway Yes Difficult Intubation Pathway Yes RSI Pathway or Difficult Intubation Pathway No Primary Ventilation or Rescue Ventilation Pathway Intubation Pathways RSI, DSI Difficult Intubation Thresholds for Stopping T.I. and Proceeding With R.V.: D.L. X 3 D.L. > 10 min. Cannot attain or maintain SpO2 92% 7

8 Confirmation of Tracheal Intubation Use what you have: Waveform EtCO2; Colorimetric CO2 Detector, Self Inflating Bulb, stethoscope, SaO2, 2 nd Look D.L., & VL ALWAYS Have a Backup Plan! SLAM Flowchart } Always assess the airway for difficulty 6 D method } Promotes Oxygenation & Ventilation over Tracheal Intubation } Promotes simple techniques to prevent and overcome failed T.I. } Thresholds for when to stop attempting T.I. ASA } Always overcome difficult mask ventilation and hypoxia with Difficult rescue ventilation Airway Algorithm James M. Rich, CRNA, MA Department of Anesthesiology & Pain Management Baylor University Medical Center, Dallas, TX JRofDallas@gmail.com THE UPPER AIRWAY: THE LARYNX THE UPPER AIRWAY: THE LARYNX 8

9 THE UPPER AIRWAY: POSTERIOR VIEWS OF THE LARYNX Direct Glottic Exposure: Straight Blade Indirect Glottic Exposure: Curved Blade GRADING THE LARYNGOSCOPIC VIEW GRADE I - ENTIRE LARYNGEAL APERATURE GRADE II - POSTERIOR LARYNGEAL APERATURE GRADE III - EPIGLOTTIS ONLY GRADE IV - SOFT TISSUE ONLY Cormack & Lehane Grade I Cormack & Lehane Grade II ESOPHAGUS 9

10 Cormack & Lehane Grade III ASSESING THE UPPER AIRWAY: THE ORAL CAVITY EPIGLOTIS INTERARYTENOID NOTCH Assess the Airway 6-D METHOD D IS FOR DIFFICULT Look for the 6 D s: 1. Disproportion 2. Distortion 3. Decreased Range of Motion 4. Decreased Thyromental Distance 5. Decreased Interincisor Gap 6. Dental Overbite Upper Lip Bite Test: (A and A February 2003 by Dr. Khan et. Al) Demonstrated a high degree of reliability Airway Assessment 6-D METHOD Disproportion = Mallampati Test Airway Assessment 6-D METHOD Distortion AIRWAY ASSESSMENT 6-D METHOD Decreased Interincisor Gap 10

11 Airway Assessment 6-D METHOD DECREASED ROM Airway Range of Motion AIRWAY ASSESSMENT 6-D METHOD DECREASED A/O ROM AIRWAY ASSESSMENT: DECREASED THYROMENTAL DISTANCE Dental Overbite Upper Lip Bite Test GENERAL OBSERVATION OF THE HEAD AND NECK Place lower teeth beyond the vermillion of the upper lip. Highly reliable in patients who: Have teeth Have no pharyngeal pathology Can follow commands No C-spine precautions 11

12 GENERAL OBSERVATION OF THE HEAD AND NECK Take Home Message Easy Intubation Induced, Ventilated, Paralyzed Intubated after Multiple Blades & Maximal ELM Done to move the patient from the dangerous to the safe road High Incidence of False Positives Occasional occurrence of false negatives Always be prepared with backup plans A B C etc. 12