Difficult Airway Management Techniques

Facilitated Intubation Algorithm

• Developed by Daniel Davis of UCSD

• Designed to minimize errors during facilitated Intubation

Step #1: Ensuring Ventilation

• Difficult airway management Difficult airway management requires time.requires time.

• The amount of time you have in The amount of time you have in the airway is determined by the the airway is determined by the patient’s oxygenation status, and patient’s oxygenation status, and their general health.their general health.

Step #1: Ensuring Ventilation

Step #1: Ensuring Ventilation

• The most fundamental element of airway management is effective BVM usage.

• Using the BVM to it’s full potential requires 4 essential components:– Tight Seal– Jaw Thrust– Sellick Maneuver– NPA/OPA

Step #1: Ensuring Ventilation

Tight Seal

OPA

Head Tilt

Sellick’s

Step #2: Predicting Complications

• Prior to a facilitated intubation it is important to perform a pre-assessment of your patient for possible complications.

• The Mnemonic (FIRST LEMON) will help to guide you in your assessment.

Step #2: Predicting Complications

• F – Facilitated

• I – Intubation

• R – Requires

• S – Superb

• T - Techniques

• L – Look

• E – External (3-3-2)

• M – Mallampati

• O – Obstruction

• N – Neck (manual ILS)

Step #2: Predicting Complications

Step #3: Maximize 1st Attempt

• In order to minimize In order to minimize complications, it is important complications, it is important to set yourself up for to set yourself up for success on your first success on your first attempt to intubate.attempt to intubate.

Step #3: Maximize 1st Attempt

• FlexGuide Stylet

• External Laryngeal Manipulation (E.L.M)

• Head Elevated Position (H.E.P)

• Consider Miller Blade

Step #3: Maximize 1st Attempt

E.L.MH.E.P

Step #4: Assemble Team

• Minimum of 2 people, preferably 3

• MUST HAVE1. The Intubator

2. Person to watch the monitor

3. Optimally a person to assemble equipment+

Step #4: Intubator Tasks

1. Pre-oxygenate (NRB/BVM)

2. Pre-assessment (First-Lemon)

3. Determine Equipment needs

4. Perform Intubation

5. Verify Placement

6. Guard Tube Through CallShould be the person with the most experience intubating.

Step #4: Intubator Tasks

Step #4: Monitor Person Tasks

1. Ensure Patient is on the heart monitor.

2. Ensure Pulse Ox is on and functioning.

3. Have ETCO2 ready.4. Input Airway Benchmarks into LP12.

(ETT Attempt, ETT Abort, ETT Succ)5. Monitor for Desaturation/HR

Reactivity and STOP attempt if it occurs.

Intubation Task Leader.

Step #4: Monitor Person Tasks

Step #4: Equipment Person Tasks

1. Set up 1st choice blade and Backup.2. Set up 1st choice tube, have Backup

ready.3. Layout FlexGuide, be prepared to

remove regular stylet.4. Have rescue airway ready. (Combitube)5. Have tube tie prepared.6. Assist with medication

prep/administration.7. Serve as intubators right hand.

Can be an EMT, proper setup helps to mitigate problems.

Step #4: Equipment Person Tasks

First Attempt Unsuccessful

1st Attempt Unsuccessful

• Remember…..Flip a coin.1. Provide immediate re-ventilation

via BVM.

2. Next determine SaO2

SaO2 in mid-90’s

“Can’t Intubate, Can Ventilate”

SaO2 < mid-90’s

“Can’t Intubate, Can’t Ventilate”

Anterior Airway

• FlexGuide

• E.L.M.

• H.E.P

• Miller Blade

Traumatized/Obstructed Airway

• Suction

• Magills

• Combitube

• FlexGuide

• Cricothyrotomy

Prevent Hypoxic Arrest

Prevent Hypoxic Arrest

SaO2SaO2 Above Above 90%90%

•Consider another intubator,

•BVM only

•FlexGuide

Prevent Hypoxic Arrest

SaO2SaO2 Below Below 90%90%

•Combitube

•Cricothyrotomy

•BVM

Summary

• Facilitated Intubation is a HIGH RISK PROCEDURE

• The Goal of all airway procedures is to provide ADEQUATE VENTILATION

• By improving the procedure we use to intubate, we can decrease adverse events from occuring.