Emergency Cricothyrotomy

Transcription

1 Emergency Cricothyrotomy SWORBHP Live Paramedic Rounds June 15, 2012 Sameer Mal PGY4 Emergency Medicine Dwayne Cottel Regional Paramedic Educator

2 Overview BVM Ventilation Intro to Cricothyrotomy Relevant Anatomy Cricothyrotomy Medical Directive Procedure Clinical Pearls Comlications Summary 1 1

3 Objectives Describe emergency techniques for BVM and available airway adjuncts Recognize a failure when attempting to secure an airway Identify the indications and contraindications of a surgical airway as per the Cricothyrotomy Medical Directive Describe the relevant anatomy associated with Cricothyrotomy Demonstrate the correct insertion and postinsertion management of a Cricothyrotomy tube. 2 2

4 Bag-Valve-Mask Ventilation The most important airway skill and cornerstone of airway management Universally available Keeps you out of airway disasters Safety net! 3 3

5 Traditional Technique C-E technique Anesthesia modality Paramedics perform to avoid airway disaster BVM ventilation is difficult in 1/3 pts in whom intubation has failed 4 4

6 Two-Thumbs-Down Technique Both thumbs and palms to manipulate mask seal Both sets of 4 fingers to bring mandible anteriorly to the maxilla (jaw thrust) 5 5

7 Advantages Palms surround mask so you can feel air leaks Maximal mask maneuverability Strong muscles of hands and arms 6 6

8 Clinical Pearls Apply mask with bag detached Separate skill part of procedure Bulky, irrelevant to mask seal Insert oral and two nasal airways 7 7

9 Supraglottic Airways Excellent rescue devices Blind insertion, technically easier than BVM ventilation Delivers air directly to the glottis Literature to support as first line agent in obese patients 8 8

10 King LT 9 9

11 The Nightmare Scenario CAN T INTUBATE + CAN T VENTILATE (BVM or King LT) **FAILED AIRWAY** 10 10

12 Emergency Cricothyrotomy Essential skill as it is the ultimate failsafe Endpoint of can t intubate, can t ventilate Most important is practice Next step is quick recognition of the situation that calls on this skill 11 11

13 Cricothyrotomy, What is it? Utilized for securing a patients airway when all other methods have failed Cannulation below the glottis Two types: Needle and Surgical Percutaneous transtracheal ventilation Temporary procedure (Sanders, McKenna, Lawrence, & Quick, G., 2007) 12 12

14 What s the Difference? Cricothyrotomy Tracheotomy 13 13

15 Anatomical Landmarks The larynx consists of 9 cartilages 6 are paired 3 are unpaired All connected by muscles and ligaments The order of cartilages from superior to inferior are: 1. Thyroid (unpaired) 2. Arytenoid (paired) 3. Cricothyroid Membrane (insertion location) 4. Cricoid (unpaired) (Sanders, McKenna, Lawrence, & Quick, G., 2007) 14 14

16 Cricothyrotomy Medical Directive Patient Indications Need for advanced airway ETT and SGA unsuccessful or contraindicated Unable to ventilate Conditions Age >12 Altered LOA Contraindications # larynx Inability to landmark Mandatory Patch Point (Advanced Life Support Patient Care Standards., 2011) 15 15

17 General Procedure Dependent upon system utilized by Service Needle Cricothyrotomy Quick Trach System Surgical Insertion Seldinger System (retrograde intubation) 16 16

18 LCEMS-ACP Specific Utilize needle cricothyrotomy technique BLS suction, positioning, compressions etc. Laryngoscopy and McGill's for FBAO removal If unsuccessful, stabilize head, neck, and trachea Identify cricothyroid membrane, related structures Sterilize area with alcohol swab Patch to BHP for direction 17 17

19 Needle Cricothyrotomy Prepare 14-18G catheter 2 inches in length Connect to 10ml syringe with 5ml of NaCl 18 18

20 Needle Cricothyrotomy Palpate for the v Grab the midline Slide down to cricothyroid cartilage 19 19

21 Needle Cricothyrotomy Insert 45 through the cricothyroid membrane Aspirate for free air 20 20

22 Needle Cricothyrotomy If free air present, advance catheter toward carina Remove needle 21 21

23 Needle Cricothyrotomy Remove plunger Attach a 3ml syringe Attach a #7 ETT connector Attach BVM 22 22

24 Clinical Pearls Positioning head in extension brings airway more superficial Equipment preparedness Light Assistant 23 Suction 23

25 Ventilating a Cricothyrotomy Cricothyrotomy usually requires high frequency Jet ventilation (45-60psi) When ventilating use a ratio of 1:8 seconds Ventilate gently, allow the air to escape 8 sec. optimal to prevent barotrauma If chest remains distended, gentle compression may be needed Constant observation of patient (Sanders, McKenna, Lawrence, & Quick, G., 2007)

26 Advantages Lowest risk of the surgical airway procedures Does not compromise C-Spine control Can be accomplished quickly Effective, and inexpensive (Sanders, McKenna, Lawrence, & Quick, G.,

27 Disadvantages Airway is not protected Promotes oxygenation but does not effectively eliminate CO 2 Short ventilation time <1 hour Does not maximize lung volumes Difficult to inflate lungs due to lumen size Slow expansion and relaxation of chest wall Air trapping may occur resulting in barotrauma from overzealous ventilations (Rich, James Michael., 2008) 26 26

28 Complications Barotrauma Catheter Issues Subcutaneous emphysema Hypercapnia Damage to adjacent structures Bleeding/infection 27 27

29 Summary Good BVM ventilation technique is critical to airway success Rescue devices (SGA) are easy to insert, can help avoid worst case scenario Recognize the failed airway Practice until it becomes reflexive 28 28

30 References Sanders, M. J., McKenna, K., Lawrence, L. M., & Quick, G. (2007). Mosby s Paramedic Textbook. St. Louis, Missouri: Elsevier Mosby Ministry of Health and Long Term Care. (November 2011). ALS Advanced Life Support Patient Care Standards Version 3.0. Queens Printer for Ontario. Toratora, G. J., & Grabowski, S. R. (2000). Principals of Anatomy and Physiology. New York, New York: John Wiley and Sons Inc. Rich, James Michael. (2008). SLAM: Street Level Airway Management. Upper Saddle River, New Jersey: Pearson Education, Inc