Airway Management. Teeradej Kuptanon, MD
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1 Airway Management Teeradej Kuptanon, MD
2 Outline Anatomy Detect difficult airway Rapid sequence intubation Difficult ventilation Difficult intubation Surgical airway access
3 ICU setting Intubation Difficult Intubation Exit procedure Pulmonary hemorrhage Neck mass 5/2/2016
4 Resuscitation A Airway CCirculation B Breathing A Airway CCirculation B Breathing
5 Anatomy
6 Anatomy
7 Assess History Physical Examination Film airway ( Pediatricradiology.com)
8 5/2/2016
9 Mallampati Airway classification
10 3 times 10 minutes
11 Airway management Position Oropharyngeal Airway Nasopharyngeal airway Endotracheal tube Tracheostomy tube
12 Airway management Head tilt, Chin lift Triple maneuver Head tilt Jaw thrust Open mouth C-spine injury Supplement oxygen
13 Head tilt, Chin lift 5/2/2016
14 5/2/2016 Triple maneuver
15 5/2/2016 C spine injury
16 Sniffing position Oropharynx Pharynx Larynx
17 Oropharyngeal Airway
18 Nasopharyngeal airway
19 Indication for intubation RCA Retraction, Respiratory rate Conscious change, Cyanosis Air entry, Apnea
20 Endotracheal Intubation Put ETT (Uncuff, cuff, Tech) Uncuff Age/4 + 4 Cuff Age/ Check Off ETT
21 Endotracheal Intubation Position Blades Stylet Sellick s maneuver
22
23
24 Endotracheal tube exchanger Bougie Stylet
25 Sellick s maneuver
26 Rapid sequence intubation The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation Minimize risks of gastric aspiration
27 Rapid Sequence intubation (RSI) = 7P
28 Prepare for Intubation Pre intubation check SOAPME Suction Oxygen Airway Pharmacy/Personnel Monitoring Equipment
29 Expedient intubation requires preparation Direct laryngoscope (all sizes, types) Magill forceps Endotracheal tube (all sizes) Ambu bag, Suction, stylet, O2 source) Facemask, nasopharyngeal/oropharyngeal airway Supraglottic airway device Videolaryngoscope Emergency surgical airway kits Emergency resusciation medications
30 Preoxygenation After 2 minute; 95% of nitrogen replaced by O 2 increasing O 2 reserve Avoid!! PPV in patient who is spontaneously breathing
31 Pretreatment Medications Dose Indication Consideration Lidocaine 1-2 mg/kg/dose Head injury, TBI, elevated ICP Atropine 0.02 mg/kg/dose min 0.1 mg, max 1 mg <1yr old, 1to5yr who receive succinylcholine, and anyone with risk of bradycardia Can protect IICP during intubation Prevent reflex bradycardia
32 Induction medications Medications Dose Advantage Disadvantage Fentanyl 1-4 mcg/kg Easily reversible and short acting Risk of chest wall rigidity Midazolam mg/kg Status epilepticus Hypotension Etomidate mg/kg TBI, hypotension Adrenal insuff. May precipitate seizure Ketamine mg/kg Hypotension, asthma Propofol 1-2 mg/kg Rapid onset, status epilepticus Increased ICP, hypersecretion, glaucoma Hypotension Hypersensitivity to soy/egg
33 Paralysis medications Medication Dose (mg/kg) Advantage Disadvantage Succinylcholine 1-2 (<10 kg) (>10 kg) Rapid onset, short duration, IM use Rocuronium Quick onset, stable No significant contraindication Bradycardia, hypotension, arrhythmias, pulm edema, rhabdomyolysis Increased HR
34 Nasotracheal intubation
35 Tracheostomy tube
36 5/2/2016
37 Technique for difficult Ventilation Oral/ Nasal Airway Two-person mask ventilation Laryngeal Mask Airway (LMA) Esophageal-tracheal combitube Surgical airway access
38 2 person mask ventilation 5/2/2016
39 Laryngeal Mask Airway (LMA)
40 Laryngeal mask airway size Anesthesiology 2000;92:631
41 Combitube
42 Difficult intubation Position ด? ยก blade ถ กต อง? External laryngeal manipulation? Jaw thrust?
43 Technique for Difficult Intubation Fiberoptic intubation Blind intubation Alternative laryngoscope (Mc Coy) Video-assisted laryngoscope Illuminating stylet Retrograde intubation Surgical airway access
44 Fiberoptic tracheal intubation Indication History of difficult intubation Compromise airway Extension of the neck is not possible Awake intubation with tropical anesthesia
45 Video-assisted laryngoscope Good laryngeal view; glottis is seen in the center of the upper third of video display
46 Illuminated stylet
47 Retrograde intubation
48 Surgical Airway Access Cricothyroidotomy Tracheostomy
49 Cricothyroidotomy When attempts at intubation or ventilation have failed, cricothyrroidotomy is considered the procedure of choice. 5/2/2016
50
51 Emergency cricothyrotomy
52 Mini-tracheostomy Seldinger technique (safer than blind) Aspirate air with the needle and syringe to check placement, cut with scalpel Remove syringe, insert wire into needle, remove needle Thread dilator with airway already loaded onto wire Remove wire
53 5/2/2016
54 5/2/2016 Cricothyroidotomy
55 Exit Procedure 5/2/2016
56 5/2/2016
57 5/2/2016
58 Treatment Specific treatment cause of bleeding Correct bleeding tendency and coagulopathy Paralyze patient with muscle relaxant and sedative drug Ventilator support to maintain oxygenation and ventilation
59 Treatment Emergency management for massive hemoptysis Unilateral intubation or Double lumen ETT Rigid bronchoscope with epinephrine Vasopressin drip Selective bronchial arteriography with embolization Lobectomy
60 5/2/2016
61 5/2/2016
62 5/2/2016
63 Neck mass Lymphoma 5/2/2016
64 5/2/2016
65
66
67
68
69
70 Thank you for your attention
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Introducing the Fastrach-LMA. Prepared by Jim Medeiros, NREMT-P Regional Field Coordinator Lord Fairfax EMS Council
Introducing the Fastrach-LMA Prepared by Jim Medeiros, NREMT-P Regional Field Coordinator Lord Fairfax EMS Council Objectives Review Anatomy of the Upper Airway Review LFEMSC LMA Protocol Discuss Indications
Respiratory Management in Pediatrics
Respiratory Management in Pediatrics Children s Hospital Omaha Critical Care Transport Sue Holmer RN, C-NPT Objectives Examine the differences between the pediatric and adults airways. Recognize respiratory
Case 1: Fast and noisy. The Ins and Outs of the Pediatric Airway. Airway: anatomic differences. Objectives 2/16/2014
Case 1: Fast and noisy The Ins and Outs of the Pediatric Airway Judith Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Department of Emergency Medicine 8 month old BIB parents for
ADVANCED AIRWAY PROCEDURES
ADVANCED AIRWAY PROCEDURES This procedure includes the following: Endotracheal intubation (plus use of Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T. device), gum elastic bougie assisted tracheal