2. Airway Anatomy Soft palate Hard palate Nasopharynx Oropharynx Hypopharynx Tongue Thyroid cartilage

3. Airway Anatomy Trachea Cricoid cartilage Thyroid cartilage Hyoid bone Cricothyroid membrane

4. Airway Anatomy True vocal cords False vocal cords Epiglottis Vallecula Corniculate cartilage (arytenoids) Cuneiform cartilage (arytenoids) Pyriform sinus

5. Airway Anatomy Trachea Bronchi Carina

6. Airway management tools Chin lift / jaw thrust (most basic) BVM Airway adjuncts: oral, nasal Non-visualized advanced airways (supraglottic) Laryngeal Mask Airway (LMA) Laryngeal Tube (ie. King LT) E-T Combitube (dual lumen) Endotracheal intubation (by various means) Cricothyrotomy (most advanced) CONTINUUM IN WHICH ALL ARE IMPORTANT

7. Airway management Visualization axis

8. Prehospital decision to intubate Maintaining airway? Protecting airway? Ventilating / oxygenating adequately? Deterioration / airway compromise likely? Airway manuevers, Adjuncts Now maintained? Coma cocktail successful? Intubate BVM, intubate Coma cocktail, supp. O2 successful? Consider intubation vs. close observation Rapid transport Supp. O2, Observe, Transport no yes no yes no yes no yes

9. Difficult airways “The difficult airway is something one anticipates; the failed airway is something one experiences.” - Ron Walls

10. Difficult BVM - MOANS Mask Seal Facial hair, deformity, blood Obesity / Obstruction Cancer, lesions, excess tissue Age >55, higher risk of poor BMV No teeth Teeth keep face from caving in during BMV Stiff / Snoring Lung resistance issues (edema, COPD)

11. Difficult Intubation - LEMON Look externally Evaluate 3-3-2 ideal 3 fingers in open mouth (mouth opening size) 3 fingers chin to hyoid (size of tongue in relation to pharynx) 2 fingers hyoid to thyroid cartilage (larynx in relation to tongue base) Mallampati score

12. LEMON - Mallampati Best Worst

13. LEMON Obstruction Known issues (hematomas, cancers, etc) Muffled voice, stridor, or difficulty swallowing Neck mobility Inability to line up axis will make more difficult

14. Failed airway Definition: 1. unable to intubate by multiple attempts or: 2. failure to intubate and oxygenation cannot be maintained Need to decide which situation is in place: Can’t intubate, can ventilate – go with the basics Can’t intubate, can’t ventilate – go with the cricothyrotomy

15. Review of intubation Setup for intubation (already being ventilated with BVM) Stylet Endotracheal tubes (multiple sizes) Average male: 8.5 mm average female: 7.5 mm (8.0 and 7.0 commonly used in EMS) Laryngoscope and blades (curved and straight, multiple sizes) - check light Syringe for inflation of balloon Suction Alternate airway devices Verification method (colorimetric, capnograph, stethoscope) Securing device

16. Steps of intubation 1. Laryngoscope in left hand, loose grip with fingers 2. Position the airway (initially sniffing position if possible) 3. Open the mouth with right hand 4. Insert blade on far right side 5. Swing to the midline, moving tongue to the left 6. Upward pressure in the direction of the handle to expose the vocal cords (no levering) 7. Keep visual contact with vocal cords while obtaining ET tube

17. Steps of intubation 8. Insert tube from right corner of mouth (bevel horizontal) 9. Rotate 90 degrees (bevel vertical) and insert through the vocal cords at midline until balloon passes completely through 10. Remove laryngoscope 11. Remove stylet (hold your tube!) 12. Inflate balloon with 7 – 10 mL of air 13. Ventilate and verify the tube by multiple means 14. Secure the tube

18. Intubations http://www.youtube.com/watch?v=mvWUcP7LFMo http://www.youtube.com/watch?v=4V_pouIbcnA

19. Verification of tube placement Auscultation (stomach first?) – bilateral to check depth Chest rise Esophageal detection device Colorimetric ETCO2 device Continuous waveform capnography (“the most reliable method”) Record depth at teeth (average 21 cm in females, 22-23 cm in males)

20. Laryngoscopy techniques Cormack-Lehane grading system

21. Laryngoscopy techniques BURP manuever (similar but different from Sellick’s manuever or cricoid pressure) Backward Upward Rightward (patient’s right) Pressure Tends to improve the Cormack-Lehane grade Assistant may provide too much pressure, so you can guide them

22. Laryngoscopy techniques Intubating stylets (Bougie) Using laryngoscope, insert flexible stylet between vocal cords (grade 2) or above the arytenoids (grade 3) Slide ETT over the stylet into the trachea while keeping laryngoscope in place