#3 Intro to EM Airway Management- Assessment and SupraGlottic Airways (SGA) Andrew Brainard 1.
-
Upload
roxanne-thomas -
Category
Documents
-
view
219 -
download
1
Transcript of #3 Intro to EM Airway Management- Assessment and SupraGlottic Airways (SGA) Andrew Brainard 1.
1
#3Intro to EM Airway Management-
Assessment and SupraGlottic Airways (SGA)
Andrew Brainard
#3 SupraGlottic Airway
• Learning Objectives: – Briefly describe plan, assign roles
• Declare “Crash Airway” • Skip checklist • Continue Chest Compressions
• Place SupraGlottic Airway – Proper sized LMA/AirQ – Proper insertion (<30sec) – Troubleshoot cuff leak – Tube confirmation
• Discuss– Crash vs Emergent vs Semi-elective– Advantages/Disadvantages of SGAs – Indications for SGA, RSI, ETT
• Safe removal of SGA – Formal Airway Assessment – MOANS/LEMON/RODS – Specific briefing for Plan A, B, C, & D– Suction– Leave Cuff Up– Remove under direct visualization
• Bell in Short Stay: – 60y/o M, chest compressions in progress on
patient admitted with chest pain – On floor unresponsive – GCS 3, No pulse, CPR in progress, – Unobtainable SaO2 – Difficulty with BVM seal (beard, small jaw, no
neck, emesis, high resistance)
• Crash SGA during compressions – Insert SGA – Oxygenate and Ventilate through SGA – Get ROSC – Transfer to resus – Intubate through SGA – Discuss removing SGA
• Formal Airway Assessment – MOANS – LEMON – RODS– SHORT
3
Using SuperGlottic Airways (SGA)
Air Q
Fastrack I-LMA
• Indications• Predicting difficult (RODS)
• Sizing• Insertion Procedure• Troubleshooting• Intubating through an SGA
4
• Indication(s)– Rescue Airway– Rescue Oxygenation– Anywhere on the
Algorithm– Replacing Inadequate
BVM– During
CPR/compressions– For Pre-Oxygenation
before Laryngoscopy(Rapid Sequence Airway)
– After unsuccessful Laryngoscopy– Before/during cric
SGA/LMA
SGA/LMASGA/LMA
SGA/LMA
SGA/LMA
SGA/LMA
SGA/LMA
5
Intubating LMA (Fastrack)#3- Small Adults 30-50kgs#4- Most Adults 50-70 kgs#5- Large Adults 70-100 kgs
AirQ#1.0- Infant <7 kgs
#1.5- Toddler 7-17 kgs
#2.0- Child 17-30 kgs
#2.5- Small Adult 30-50kgs#3.5- Most Adults 50-70 kgs#4.5- Large Adult 70-100 kgs
Ideal Body Weight (height)
6
Predictors of Difficult SGA
• RODS–R: restricted mouth–O: obstruction–D: disrupted or
distorted airway– S: stiff lungs or c-spine
7
AirQ• Insertion
– Lubricate– Leave red tag on pilot balloon – Lift tongue
• Finger/Laryngoscope/Tongue depressor
– Can use finger to assist around the corner
– Jaw lift – Position incisors between 2 insertion
marks • Add ~5 cc’s of air.
• Minimizing Leaks – Neutral head position – Use jaw lift – Don’t over-inflate – Check position
• While inflated, pull back 1-3cm – Change size – Check ETCO2 waveform How to use a AirQ
http://www.youtube.com/watch?v=E0a1KYwfDk0 (9 minutes)
8
Supraglottic Airway (SGA)• Prepare/position airway• Lubricate and deflate cuff• Pull the jaw and tongue
forward– Finger– Laryngoscope– Tongue depressor
• Insert the LMA – Press against hard palate– Advance until resistance
• Inflate the cuff– Poor seal may indicate over
inflation.• Ventilate the patient with PEEP• Confirm placement
– ETCO2– Chest Rise– Listen for Leak
9
Troubleshooting SGAs
• Get best possible seal– Over-inflation is
frequently the cause of leaks
– Usually Too deep– Test airway pressures– Watch ETCO2 trace
• Chandy maneuver, – Rotate
• Sagittal• Coronal
– Lifting • Toward ceiling
10
Intubating through the LMA
• Place LMA
• Ventilate– Relax
• Insert ETT• Reattach BVM to
ETT– Ventilate w/ETCO2
• Size ETT/I-LMA– Lubricate tube– Test ETT fit
• Confirm placement– Ventilate w/ ETCO2– Confirm tube placement – Inflate ETT cuff
• Advance ETT– Applying upward
pressure on the LMA
– Ventilate w/ ETCO2– Advance ETT
through cords
• Removing the LMA is optional
• Verify placement– ETCO2– Listen
for leak
11
Airway briefing and checklist• CPR with chest compressions and BMV are in
progress.
•We are having difficulty assuring oxygenation with a BVM
• This is a crash airway
• Continue Chest Compressions
• Place the I-LMA #5
• Continue Chest Compressions
• Our plan is:•A- Continue to attempt to BVM•B- Place I-LMA #4 (now)•C- Direct/bougie/7.5 tube once we have ROSC or some more time•D- Cric if we get ROSC but can not get an airway
• Questions?
• Oxygenate the patient
12
SuperGlottic Airways (SGA)
• Indications• Predicting
difficult (RODS)
• Sizing• Insertion
Procedure• Troubleshooting• Intubating
through an SGA
13
Brief SGA References:• Thomas C. Mort The Supraglottic Airway Device in the Emergent Setting: Its
Changing Role Outside the Operating Room. Anesthesiology News, 2011- http://www.anesthesiologynews.com/download/sga_angam11.pdf (accessed on 15/6/2014)
• Daniel J Cook, AirQ Tips and Techniques Youtube- Mercury Medical https://www.youtube.com/watch?v=E0a1KYwfDk0 (accessed on 15/6/2014)
• Dr. Gallagher’s Neighborhood- Laryngeal Mask Airway: MICU Fellows Airway Course- https://www.youtube.com/watch?v=-oXa-f5qkGY&index=5&list=PLDvE6n0oI4ehBbTL_OAMeFQvJmJFz6tGU (accessed on 15/6/2014)
• Nichole Bosson- Laryngeal Mask Airway, Emedicine: http://emedicine.medscape.com/article/82527-overview#a15 (accessed on 15/6/2014)