CAP – Module 4 DIFFICULT AIRWAY MANAGEMENT GHEMS_V11292018

Objectives Review Anatomy and Physiology Review the approach to the difficult airway Review the protocols associated with difficult and failed airway management Review the difficult and failed airway algorithms

A&P Review Upper airway Nasopharynx Oropharynx Laryngopharynx Larynx OBJ: anatomy review: depth should be tailored to needs of least experienced operator

A&P Review Glottic structures Glottic opening Vocal cords Cuneiform cartilage Corniculate cartilage Together make up the Arytenoid Cartilage

A&P Review Laryngeal landmarks Thyroid cartilage Cricothyroid membrane Cricoid membrane Thyroid gland OBJ: important to correlate laryngeal anatomy with surface anatomy landmarks

Airway Management – Difficult Airway Indications: All Prehospital airways should be considered difficult to some degree. The provider must have preexisting criteria for predicting possible difficult airway situations and a set algorithm based on agency resources and County protocols for managing the difficult airway. Critically ill patients will de-saturate quickly, possibly resulting in a failed airway situation. OBJ: major points: predicting the difficult airway, having a plan (algorithm)

Airway Management Approaching the Difficult Airway Predicting Use the LEMON pneumonic L - Look Externally E - Evaluate with 3-3-2 rule M - Mallampati score O - Obstruction N - Neck mobility Look Externally: beard, dentition, obesity, etc.

Look Externally For every patient who may require intubation, the paramedic should always look for readily apparent, even cosmetic, characteristics that may predict a potentially difficult airway. These include among others; obesity, micrognathia, evidence of previous head and neck surgery or irradiation, presence of facial hair, dental abnormalities (poor dentition, dentures, large teeth), a narrow face, a high and arched palate, a short or thick neck, and facial or neck trauma.

External look

3-3-2 Rule

Mallampati Score Mallampati, Cormack and Lehane scores OBJ: Mallampati may be obtainable on initial patient evaluation, with patient sitting in sniffing position; this slide attempts correlation with the laryngoscopic view of the Cormick Lehane system, which is basically a predictor of ET placement success

Obstruction Foreign body Trauma Swelling Esophageal spasms Growth Infection

Obstruction list discussion Foreign body – remove by direct laryngoscopy and Magill forceps Trauma – Follow protocols and airway algorithms Swelling – Follow protocols and airway algorithms Esophageal spasms – Use of Succinylcholine Growth – Follow protocols and airway algorithms Infection – Follow protocols and airway algorithms

Neck Mobility Arthritis Spinal immobilization Location of patient Entrapment – discuss possibilities

Decision Making Question One Is Ventilation Adequate or Inadequate? Question Two Is the Airway Normal or Disrupted? Another approach to determining the difficult airway, answering these two questions and applying them to the grid below

Decision Making: Ventilation Adequate Inadequate SaO2 > 90% Also note respiratory rate, effort EtCO2 spot reading may be unhelpful (e.g. CO2 retainers) SaO2 < 90% Note baseline may be below 90% Also note respiratory rate, effort Note: SaO2 is the key part of the definition. SaO2 below 90% may be baseline for a patient, but does not mean physiologically that patient will have a correspondingly lower set point to rapid desaturation; it is hemaglobin-dependent. These patients should be considered essentially in the failed airway protocol from the start.

Decision Making: Airway Normal Airway Disrupted Airway Still identified as technically difficult Anatomy intact Examples: Obesity Anterior glottis Small mouth Still identified as technically difficult Abnormal anatomy Examples: Trauma/burn Infection Hematoma Cancer Foreign body Note here that Normal Airway dose not equate with non-Difficult Airway

Decision Making: Resources Supraglottic Infraglottic Combitube PROC 120 Eschmann catheter (“bougie”) PROC 100 Percutaneous cricothyrotomy (Rusch quicktrach) PROC 290 Surgical cricothyrotomy Retrograde is so operator-dependant it should be discouraged as a resource for those not practiced with it. Resources will not be available in all agencies. Fiberoptic is not readily available as of early 2008, but many products are on the horizon and should be expected to penetrate the prehospital environment in the near future.

Airway Management – Difficult Airway Approaching the Difficult Airway Call for additional assistance Maximize your chances Position, medications, dentures out if needed Have a PLAN BVM/airway adjuncts RSI Partner tries or second try with different blade ET introducer “Eschmann catheter” Multi-Lumen Airway “combitube” OBJ: reemphasize the need to have a plan/algorithm

Difficult Airway Algorithm Call for additional assistance Move to failed airway algorithm No Able to BVM Pt w/adjuncts Yes Follow post intubation protocol Yes RSI completed No Try with a different blade/partner tries RSI completed Yes No Yes Use Eschmann Catheter RSI Completed No Move to failed airway algorithm

Airway Management – Failed Airway Indications: provider is unable to secure a definitive airway. Definition Oxygen saturation is below 90% after one attempt at ETT OR Three failed attempts at ETT Management Combitube: bridging airway until definitive airway is placed Cricothyrotomy: surgical airway is definitive, non-surgical (e.g. “quicktrach”) is not

Failed Airway Algorithm Call for assistance Failed Airway criteria met Cricothyrotomy No Able to BVM patient? Yes Consider Combitube No Time allows and successful? Yes No Able to maintain SpO2>90% Yes Arrange for definitive Airway Management

Airway Management Questions?