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31 Cards in this Set
- Front
- Back
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What is a difficult airway?
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pt is: difficult bag/mask ventilation difficult laryngoscopy and intubation or difficult cricothyrotomy |
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What are some causes of difficult airway?
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external/physical factors: atlanto-occipital movement, limitation of mouth opening, protruding teeth, thyromental distance, sternomental distance, mallampatti score, receding mandible, short neck congenital factors: Pierre robin, treacher collins, goldenhar's, down's, klipperl-feil, meckel's acquired/infection: epiglottitis, croup, ludwig's angina, tonsillitis trauma/emergent: facial, cervical injury, hematoma, anaphylaxis, burns, halo/body cast, prior head/neck conditions/diseases: obesity, sleep apnea, pregnancy, goiter, acromegaly, radiation therapy arthritis hidden factors |
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What are the 3 cardinal signs of obstruction?
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muffled voice difficulty swallowing secretions stridor |
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Name some causes of difficult bag/mask ventilation.
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M ask seal O bstruction/obesity A ge N o teeth S tiff/snoring |
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What 6 components are part of a best laryngoscopy attempt?
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1) experience endoscopist 2) paralyzed 3) optimal sniff position 4) BURP 5) appropriate blade length 6) blade type |
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What is a difficult airway?
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one in which a difficult airway is identified, the difficult airway algorithm is used and the approach is therefore different from that takenwhen the patient is not anticipated to have a difficult intubation
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What is a failed airway?
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when a provider has embarked on a certain course of airway management and has identified that intubation by that method is not going to succeed, requiring immediate initiation of a rescue sequence -can be called a difficult airway -exists when there is either a failure to maintain acceptable O2 sats during one or more failed attempts or three failed attempts by an experienced intubator with normal O2 sats |
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When do you go to the Failed Airway Algorithm?
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Failed first intubation -> reposition head/neck, BURP, muscle relaxant Second failed attempt -> switch blades, use neck hyperflexion, use specialized blade, use bougie Third attempt -> go to algorithm |
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What is step 1 of the difficult airway algorithm?
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Assess likelihood and clinical impact of basic management problems: difficult ventilation, intubation, patient cooperation or tracheostomy
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What is step 2 of the difficult airway algorithm?
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actively pursue opportunities to deliver supplemental O2 t/o process of difficult airway management
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What is step 3 of the difficult airway algorithm?
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Consider the relative merits and feasibility of basic management choices A: awake vs intubation after general B: non-invasive for initial approach vs invasive C: spontaneous breathing vs no breathing |
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What is step 4 of the difficult airway algorithm?
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Develop primary and alternative strategies
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You've decided on an awake intubation. Talk me through that decision tree.
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Initial decision is: Invasive airway access or non-invasive intubation - Non-invasive succeeds (yay) or Non-invasive intubation fails -> cancel case, consider other options or invasive airway access |
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You've decided on intubation after induction of general anesthesia. What is the first part of that decision tree?
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Initial intubation attempts successful (yay) or attempt unsuccessful -> consider 1. calling for help 2. return to spont breathing 3. awaken patient |
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You're initial intubation attempt was unsuccessful. What do you do next according to the difficult airway algorithm?
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Big question: Can you ventilate?? yes I can face mask ventilate = non-emergency pathway no I cannot face mask ventilate = LMA |
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You are having difficulty with face mask ventilation and have decided to place a LMA. What is next according to the difficult airway algorithm?
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Attempt LMA LMA adequate --> non-emergency pathway LMA not adequate --> emergency pathway |
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Describe the Non-emergency pathway of the difficult airway algorithm.
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Ventilation adequate, intubation unsuccessful --> perform alternative approaches to intubation if fail after multiple attempts then: 1) invasive airway access 2) consider feasibility of other options 3) awaken patient |
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Describe the emergency pathway of the difficult airway algorithm.
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ventilation not adequate, intubation unsuccessful: call for help (can go straight to emergency invasive airway access here) attempt emergency non-invasive airway ventilation (if this fails, go to invasive) if successful then: 1) invasive airway 2) consider other options 3) awaken patient |
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List some "other options" as suggested per the difficult airway algorithm.
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surgery using face mask or LMA LA infiltration or regional nerve block |
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List some alternative approaches to intubation per the difficult airway algorithm.
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use different blade LMA as an intubation conduit fiberoptic intubation intubating stylet or tube changer light wand retrograde intubation blind oral or nasal intubation |
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What are some options for "emergency non-invasive airway ventilation"?
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rigid bronchoscope esophageal-tracheal combitube ventilation transtracheal jet ventilation |
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What are the steps of an emergency cricothyrotomy?
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1) identify cricothyroid membrane 2) make vertical incision in midline 3) advance needle until air is aspirated 4) remove syringe and needle, leading catheter, advance guide wire into airway through catheter 5) Remove catheter 6) place the airway tube |
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What are some indications for awake intubations?
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anticipated difficult airway unstable neck fractures patients in halo devices small or limited ability to open mouth |
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How do you provide anesthesia for the mouth?
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have patient gargle and swish with 4% aqueous solution of lidocaine or use an atomizer or give nebulizer with 4mL of 4% lidocaine |
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Glossopharyngeal Block
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blocks oropharynx, soft palate, posterior portion of tongue and pharyngeal surface of epiglottis -insert needle behind midpoint of the posterior tonsillar pillar and directed laterally inject 2 cc 2% lidocaine *has risk of carotid injection (can also block by holding swabs soaked in LA or swish and gargle) |
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Superior Laryngeal Nerve Block
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sensation to base of tongue, posterior surface of epiglottis, aryepiglottic fold and arytenoids -can block with mucosal saturation by inhalational and direct topical application -locate hyoid bone, displace to side, inject at inferior border of cornu |
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Recurrent Laryngeal Nerve Block
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provides comfort and prevents coughing while ETT is being placed -inhalational technique works well |
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Transtracheal Block
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injection of LA through cricothyroid membrane puncture membrane, aspirate air, inject 3-4ml 4% aqueous lidocaine |
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How do you do a blind intubation?
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listen and feel air movement. . . . use 4% cocaine and lidocaine if meet resistance, rotate 90 degrees breath sounds increase as you get closer CI in apneic, combative, anatomically disturbed airways, ICP, basilar skull fracture, etc |
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Transtracheal Jet Ventilation
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a technique for the cannot ventilate/cannot intubate scenario temporary fix needle with syringe inserted through cricothyroid high-pressure noncollapsible tubing manual jet ventilator/insufflator device high-pressure O2 source at 10-15L watch out for barotrauma |
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What are some CI to fiberoptic intubation?
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excessive blood and secretions foreign body or upper airway obstruction inadequate oxygenation by bag and mask |
