Transcript File
Amy Gutman MD [email protected] Anatomy & Physiology Ventilation & Oxygenation Decision-Making Algorithms Pediatric Airways You are called to the scene of a morbidly obese male with complaint of “short of breath”. He is in obvious respiratory distress, then becomes apneic You make one attempt to endotracheally intubate, but have significant difficulty due to his body habitus, large tongue, & short neck The patient rapidly decompensates; attempts made to BVM ventilate & oxygenate are failing What is your next step? A: Tongue Edema Post Lye Injury B: Neck Injury With Epiglottis Swelling Respiration involves entire exchange circuit Inhaled O2 O2 & Co2 exchange at alveolar-capillary membrane Capillary bed perfusion CO2 exhaled gas Subjective Respiration quality Pulse quality Mentation Objective Respiration & Pulse rate BP O2 Sat ETCO2 GCS The act of placing oxygen on a patient does not necessarily improve ventilation or respiration Delivery Liters O2% Nasal Cannula 1-6 24-40% Simple Mask 8-10 40-60% NRB 10 60% Venturi 4-10 24-50% BVM 12 + Reservoir >90% General Concepts “Basic” Advanced Airways “Advanced” Advanced Airways Biluminal Airways Every airway is a difficult airway until that patient has a confirmed tracheal tube Just because you have never missed an airway, do not assume that you never will Limit problems by anticipating that everything is just a minute away from becoming a SNAFU Weigh benefits vs risks of intubation Rapid transport with efficient BVM often the better airway management technique Properly position Facilitate O2 delivery OP/ NP airways CPAP Breathing treatments if needed Calm patient down Drive faster (& safer) Maintaining & Protecting Airway? Ventilating? Oxygenating? Yes Successful Unsuccessful BVM Advanced Airway O2 Transport Yes No Reposition, O2 Dextrose Narcan Likely deterioration? No Rapid Transport BVM CPAP Advanced Airway “Master BVM. There are few airway emergencies in the prehospital setting not managed adequately with proper bag & mask ventilation until the patient can be transported to the hospital” ~Ron Walls MD Maintain airway: Jaw-thrust, head-tilt, chin-lift OPA, NPA Ventilation Assistance Synchronous & rhythmic Maintain seal & low airway pressures Don’t forget O2! Hypercapnia Too fast Hypotension secondary to increased intrathoracic pressures Hypocapnia Too slow Brain injury due to cerebral vascular constriction Can’t Intubate, Can Ventilate 2 unsuccessful intubation attempts BVM maintains O2 sat > 90% Can’t Intubate, Can’t Ventilate 2 unsuccessful intubation attempts Cannot maintain O2 sat > 90% with BVM ETI / NTI Unsuccessful Alternatives: Biluminal LMA Combitube Lighted Stylette Cricothyrotomy Or Retrograde Successful Successful Post Airway Management A: “Alternate” Tube Blade Approach B: “Blind, BVM, Bougie” Blind BVM Bougie-assisted C: “Cric” Surgical Airways Anatomy Obesity Short/ muscular neck Protruding incisors Arched / high palate with long/ narrow oropharynx Edematous mouth/ neck/ chest Other Neck trauma Cannot jaw opening (i.e. c-collar) Cannot move neck (i.e. trauma) 3 Finger Mouth Opening 3 Finger Chin to Hyoid 2 Finger Mouth to Thyroid L E M O N Look Externally Evaluate 3-3-2 Rule Mallanpati Score Obstruction Present Neck Mobility Edentulous Obesity Facial Hair Protruding/ buck teeth Protruding tongue Facial/ neck trauma M allampati Scoring Class 1 Soft palate, uvula, anterior & posterior pillars Class 2 Soft palate, uvula Class 3 Soft palate, base of uvula Class 4 Soft palate not visible Neck trauma Laryngeal crush injuries Foreign body obstruction Food Tumor Edema Burns Anaphylaxis Cannot manipulate in trauma patients Ability to flex, extend or manipulate head/ neck of non-trauma patient can increase likelihood of visualizing cords You GUARANTEE Failure If You Do Not Prepare! Preoxygenate, BVM, Full O2 tank 2 large bore IV / IO & IVF Monitor 2 sizes ETT, checked cuffs, back-up Blade, checked light, back-up Alternative airway checked Handle, checked batteries, back-up Stylette, back-up Suction McGills ETCO2 detector, back-up Syringe x 2 Manpower & tape Endotracheal Digital Bougie Nasotracheal LMA Supraglottic Awake Fiberoptic Videoscope Surgical Endotracheal Intubation Neutral to head-tilt / chin-lift (no trauma) Scissor open mouth with right hand Remove dentures or foreign bodies Grasp laryngoscope in left hand If using a Miller, pass to right of the tongue, advance into hypopharynx, pushing tongue to the left Lift laryngoscope up & forward to expose vocal cords If using a Macintosh: advance blade into hypopharynx, lift epiglottis with blade tip expose vocal cords The blade tip fits below epiglottis (not visible with blade in position) Pass tube through cords into trachea so balloon just passes cords Pressing posteriorly on anterior neck at larynx level helps bring an anterior larynx into view BURP: Backwards, Upwards, to the Right, with Pressure Withdraw stylette Ventilate with 100% O2 Confirm tube position Listen over stomach & BL chest Fog in tube No epigastric sounds ETCO2 (waveform after capnogram) Note position of tube at teeth Inflate the cuff with 10cc syringe Tape, tape, tape! Unconscious, No gag, Unconventional Lift tongue, pull mandible forward Slide middle & index fingers down tongue Palpate epiglottis with middle finger Slide ETT between tongue & finger under epiglottis into trachea Anterior, difficult cord visualization Angled tip “clicks” when passing through glottal opening onto trachea rings allowing ETT to be passed over it into the trachea Thread ETT over bougie and advance it to a depth of 20-24 cm Confirm ETT placement Anticipated difficult airway, difficult BVM Patient must be semi-alert / conscious Contraindicated in uncooperative patients, coagulopathic, or head trauma High secondary infection rate, often significant bleeding Generous lubrication Insert along floor of nasal cavity into hypopharynx As patient exhales, gently & rapidly advance tube into trachea Confirm placement Variable sizes of traditional & intubating LMAs Seals around glottic inlet Downsides: NOT a definitive airway High risk of aspiration Best for the OR Upsides Adult & pediatric sizes Fairly simple to place Hyper oxygenate Check cuff Lubricate posterior cuff Head neutral or slightly flexed Insert following hard palate (use index finger to guide) Stop when met with resistance Inflate cuff until “rises” & secure Confirm & secure Difficult or failed intubation, full stomach, neck trauma PPE (patients cough in your face) Open airway with laryngoscope Wait for patient to cough or exhale – observe for bubbles or “white flash” indicating cords Insert ETT & confirm Unconscious, difficult airway, failed airway, primary Blind insertion with neck in neutral position Contraindicated if gag reflex, esophageal disease, ingested caustic substances Anatomically shaped distal tip assists passage behind larynx into normally collapsed esophagus Allows PPV >30cm H2O ventilation regardless of placement in esophagus or trachea Choose size & test cuff Apply lubricant to beveled distal tip Hold King with right hand; open mouth & lift chin with left hand Rotate King so blue line touches corner of mouth; insert tip into mouth As tip passes tongue, rotate tube back to midline so that blue line faces chin Advance tube until base of connector aligned with gums Inflate cuff & confirm placement More an ED / OR than EMS skill Orally or nasally Apply 2% lidocaine to oropharynx Use oral airway to protect equipment Introduce lubricated ETT in midline following base of tongue, pass uvula, behind epiglottis & between vocal cords until carina visualized Advance until cords in center of visual field: Rotate, flex, advance, rotate, flex, advance until ETT tip 3-5 cm above carina Remove scope, confirm airway Alternative to direct laryngoscopy Restricted oropharyngeal views Airway obstructions Nasotracheal intubation adjunct Tube exchange Educational Open patient’s mouth & insert glidescope exactly as you would a laryngoscope Watch video screen, not patient When cords visualized, slide lubricated ETT alongside glidescope until visualized on screen passing cords Remove handle, inflate cuff, confirm placement Seldinger Technique Wire through a needle Downsides: Difficult to perform Difficult to master Long procedure Not really an EMS skill Locate cricothyroid membrane Insert 16g needle in membrane midline at a 45 degree angle towards feet After “pop” through membrane, advance needle 1 cm Aspirate needle + catheter Secure catheter & ventilate via BVM, or continue to surgical cricothyrotomy Does not provide adequate ability to ventilate in the adult Place patient supine with neck slightly extended In-line stabilization if cervical trauma suspected Locate cricothyroid membrane midline between thyroid cartilage (Adam’s apple) & cricoid cartilage Prep overlying skin Puncture cricothyroid membrane at 90° angle Confirm needle entry into trachea by aspirating air Change hand angle to 60°; slide catheter sheath forward to stopper hub level Advance plastic cannula as you remove needle & syringe If cuffed, inflate with 2-3cc Begin ventilation when needle & syringe removed • Cut 1.5-cm longitudinal midline incision over cricoid & thyroid cartilages • Separate skin edges to see cricothyroid membrane • Make a transverse stab incision through membrane into trachea • Push scalpel handle into membrane opening & rotate 90 degrees • Use scissors to extend tracheal incision, tracheal hook to grab tracheal rings, & grasp skin edges with hemostats • Introduce 5.0-6.0 ETT into trachea with bevel pointed caudally to 1cm above endotracheal balloon, which is then inflated • Secure ETT Ventilate patient, observing for chest rise & fall Auscultate for BL breath sounds If absent, ETT may be in neck subcutaneous fascia or esophagus Remove & attempt to re-insert Secure device Continuous evaluation & documentation of oxygen saturation, ETCO2, vitals Notify ED of Priority 1 patient • Direct Visualization • Lung Sounds • Tube Condensation • Colormetric capnography followed by continuous waveform ETCO2 capnography • Pulse Ox improvement • Vital signs stabilization • Serial examinations / reassessments Preoxygenate, BVM, Full O2 tank 2 large bore IV / IO & IVF Monitor 2 sizes ETT, checked cuffs, back-up Blade, checked light, back-up Alternative airway checked Handle, checked batteries, back- up Stylette, back-up Suction McGills ETCO2 detector, back-up Syringe x 2 Manpower & tape Relatively large head & tongue Anterior pharynx Cricoid cartilage narrowest part of airway Long, floppy, omega-shaped epiglottic Easily compressed tracheal rings Compliant chest wall Retractions Airway collapses at lower lung volumes Laryngomalacia, stridor High O2 Consumption 6-10 cc O2/Kg/Minute Less reserve = quick deterioration PMH Prematurity Hospitalizations/ Illnesses Previous intubations When did child become ill? Choking/ coughing? How fast is child deteriorating? Fever? Allergies/ Medications? What’s been done so far? Comfortable vs distressed Rate Too fast vs too slow Noisy? Wheeze, stridor, silent? Position Supine, sitting, tripod Color Unreliable; pink, grey, cyanotic, ashen Symmetric Adult: 12 – 20 breaths/ minute Child: 18 – 30 breaths/ minute Infant: 30 – 60 breaths/ minute Wheeze Lower airway obstruction Usually expiratory Stridor Upper airway obstruction Usually inspiratory H. influenzae bacteria usually found in unimmunized or immunocompromised children (now in adults as well) Rare but life-threatening High fever, “toxic” child, sudden onset Tripodding, drooling Stridor Do not look in airway!!!!! Blow-by O2, & drive fast Anticipated difficult airway or epiglottitis Your own inexperience Improper equipment Short transport time with easy BVM Newborn: 3.5 mm 4 - 12 Months: 4.0 mm Older Child: 4 + Age in Years/ 4 Why & what intervention was necessary i.e. respiratory distress Condition before & during treatment Vital signs including O2 sat Document CO2 level prior to application, and during treatment – print out the summary Pre-Intubation Vitals Respiratory effort + sat, HR, BP, GCS Rationale for advanced airway Laryngoscopy: Tube size Placement at lips Passed through cords No epigastric sounds + BL breath sounds + ETCO2 w/ waveform Q 5 minute vitals + tube rechecks Maine Department of EMS. “Advanced Airway Training”. 2010 S Hopkins RN. “Equipment Review”. Condell Medical Center EMS System. 2008 Proulx A, MPAS, PA-C. “Airway Management in the Combat Casualty”. 2011 Emergency Medicine: A Comprehensive Study Guide, Tintinalli, 6th ed, McgrawHill, 2004 www.myrusch.com Ron Walls “Textbook Emergency Airway Management” (2011) Difficult Airway Site (www.theairwaysite.com) Brady & Caroline Paramedic Texts NAEMSP position papers on RSI, Prehospital intubation 2nd & 3rd degree burns to face, OP, ear, scalp, nares, melted dental plate Know your anatomy Know your options Practice those options Good BLS often better than ALS with difficult patients Know when to say when! 1 month later!