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In The Name Of God

Airway
Management
Introduction
Directed By:
Behdad Bazargani
M.D.
Anesthesiologist

Ali Shah Abbasi M.D.


Anesthesiologist
CPR consists of:

1. Airway Management
2. Basic Life Support (BLS)
3. Advanced Cardiac Life Support (ACLS)
4. Advanced Trauma Life Support (ATLS)
5. CPR in special situations
6. Ethical Issues
History

1966 :
National research council conference
(generated standards).
2005 :
American Heart Association (AHA).
Introduction
CPR:
Systematic efforts for relief patient from
situation which threatened the life.
Effective CPR:
Artificial delivery of oxygenated blood to
systemic circulatory beds at rates
sufficient for preserving vital organ
function and physiologic substrates.
Survival
Highest survival rates and quality
of survival are attained when:

- BLS is initiated within 4 min

- ACLS is initiated within 8 min


Management of CPR
It is a team effort.
Coordination of the team is the responsibility
of the team leader (Ideally Anesthesiologist).
Responsibilities of the team leader:
1- Ensure the quality of BLS.
2- Facilitate early use of electrical defibrillation.
3- Direct and monitor the adequacy of drug
therapy.
4- Ultimately, the team leader decide when
CPR should cease.
Indications

1. Unconscious (unresponsive)
2. Abnormal breathing, although there
may be brief irregular, gasping breaths
3. Pulselessness or non effective
circulation
4. Traumatic patient (electrical, drawing,
crash, car accident, )
To handle a CPR

1. Avoid agitation
2. Have a good knowledge
3. Have a good physical ability
What to
do First?
New Developments

Elimination of lay rescuer assessment of


signs of circulation before beginning chest
compressions.
Simplification of instructions for rescue
breaths should be given over 1second with
sufficient volume to achieve visible chest
rise.
Elimination of lay rescuer training in rescue
breathing without chest compressions.
New Developments
Recommendation of a (universal)
compression-to- ventilation ratio of 30:2 for
single rescuers of victims of all ages (except
newborn infants).

Increased emphasis on the importance of


chest compressions: rescuers will be taught
to push hard, push fast (at a rate of 100
compressions per minute), allow complete
chest recoil, and minimize interruptions in
chest compressions.
New Developments
Recommendation for provision of about 5
cycles (or about 2 minutes) of CPR between
rhythm checks during treatment of
pulseless arrest. Rescuers should not check
the rhythm or a pulse immediately after
shock deliverythey should immediately
resume CPR, beginning with chest
compressions, and should check the
rhythm after 5 cycles (or about 2 minutes)
of CPR.
New Developments
Recommendation that all rescue efforts,
including insertion of an advanced airway (eg,
endotracheal tube, esophagealtracheal
combitube [Combitube], or laryngeal mask
airway [LMA]), administration of medications,
and reassessment of the patient be performed
in a way that minimizes interruption of chest
compressions.

Recommendation of only 1 shock followed


immediately by CPR (beginning with chest
compressions) instead of 3 stacked shocks
for treatment of ventricular fibrillation/
pulseless ventricular tachycardia.
Thanks
For Your
Attention
Airway
Management
Directed By:
Behdad Bazargani M.D.
Anesthesiologist

Ali Shah Abbasi M.D.


Anesthesiologist
Conditions need Airway management

General anesthesia

Respiratory failure

Airway obstruction

CPR
Airway Anatomy

Nose
1.Nasopharynx
Pharynx
2.Oropharynx
Larynx
Trachea
Airway Anatomy
Airway Anatomy
Emergency Airway Management
Evaluation

Level of consciousness
-Alert
-Responds to verbal stimuli
-Responds to painfull stimuli
-Unresponsive
Airway
-Patent
-Clear
Trauma to cervical spine
Techniques of Airway Management

Non-invasive
-Head positioning
-Removal of foreign body
-Suctioning
-Mask ventilation
Invasive
-ETT
-LMA
-Combitube
Airway obstruction
Head tilt chin lift & Head tilt jaw trust
Mask ventilation
One hand mask holding
Two hand mask holding
Oral Airways
Disposable Berman Airways
Hudson Cath-Guide Airways
Rusch Berman Airways
Rusch Color Coded Guedel Airways
Oral Airway
Nasopharyngeal Airway
Rusch Latex Free Nasopharyngeal
Airway
Nasopharyngeal Airway
Endotracheal
Intubation
Indications for
endotracheal intubation
1. Provides relative protection against
pulmonary aspiration.
2. Maintains a patent conduit for respiratory
gas exchange.
3. Provides a means for coupling the lungs to
mechanical ventilators.
4. Establishes a route for clearance of
secretions.
5. Provides a route for drug administration.
Equipments

Laryngoscope Lubricant
Tubes Forceps (Magill)
Oxygen source Adhesive tape
Bag & Mask Stylet
Suction Syringe
Stainless Laryngoscope Blades
Laryngoscope Blades
Tracheal Tube
Airway Anatomy
Uncuffed Tracheal Tube
Endotrol Tracheal Tube with
Controllable Tip
EMT Emergency Medicine Cuffed Tube
with Injection Port
ETT sizes

Male: No. 8 + 0.5

Female: No. 7 + 0.5

Age
Children: No = 4 + 4 (or 3, for cuffed)
ETT : sizes (pediartics)
ETT Depth of insertion

Age
Depth(cm) = + 12
2

Male: 23 cm

Female: 21 cm
ETT : Depth of insertion
Sniffing Position

35o

80o
Incorrect position
Incorrect position
Sniffing Position
Incorrect position
Incorrect position
laryngoscopy
laryngoscopy
laryngoscopy
Sniffing Position
Laryngeal Mask Airway
Laryngeal Mask Airway
Laryngeal Mask Airway
Laryngeal Mask Airway
LMA-Fastrach
LMA- Fastrach
LMA- Fastrach
LMA-Fastrach
Examples of clinical airway problems
managed with the LMA
Acromegaly
Ankilosing spondilitis
Rheumatoid arthritis
Facial burns
Failed airway in obstetric patients
Failed rigid broncoscopy
Fractured jaw
Temporomandibular joint disease
Limited mouth opening
Micrognathia
Neck contracture
Fix immobile cervical spine
Ossification of posterior longitudinal ligament
Cervical spinal tumor
Treacher Collins
Pierre Robin
Unstable neck
Characteristics of the LMA
Sizes Weight (Kg) Cuff Vol.(ml)
#1 <5 4
#1.5 5-10 7
#2 10-20 10
#2.5 20-30 14
#3 30< 20
#4 normal 30
#5 large 40
THE LMA IS NOT
DISPOSABLE
Advantages of Using the LMA
leaves providers hands free
patient can produce effective cough
allows spontaneous ventilation
even malpositioned can adequately
ventilate
Disadvantages of LMA over the ETT

Lower seal pressure


Higher frequency of gastric
insufflation
Increased Aspiration risk
LMA Complications

Aspiration

Coughing

Sore Throat
Combitube
Combitube
Retrograde intubation
Retrograde Intubation
Retrograde Intubation
Retrograde Intubation
Retrograde Intubation
Retrograde Intubation
Cricothyrotomy
Cricothyrotomy Devices
Cricothyrotomy
Cricothyrotomy

Placement of
Needle
Cricothyrotomy

Wire Guide and Catheter In Place


Cricothyrotomy

Catheter, Dilator and Wire Guide In Place


Cricothyrotomy
Rusch QuickTrach
Jet Ventilation
Jet ventilation Catheter
Thank you
Awake Intubation
Directed By:
Behdad Bazargani M.D.
Anesthesiologist

Ali Shah Abbasi M.D.


Anesthesiologist
Indications

1. Respiratory failure
2. Decrease LOC
3. Difficult airway
Respiratory failure

Status Asthmaticus
Status Epilepticus
Pulmonary Edema
Chest wall injuries
Etc
GCS
Motor:
Category score
Obeys 6
Localizes 5
Withdraws 4
Flexion 3
Extension 2
None 1
GCS
Verbal response:
Category score
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
GCS
Eye opening:
Category score
Spontaneously 4
To speech 3
To pain 2
None 1
GCS =or< 8

Intubation
Equipments

Laryngoscope
Tubes
Oxygen source
Bag & Mask Drugs
Suction
Lubricant
Ventilator
Forceps (Magill)
Adhesive tape
Stylette
Syringe
Drugs
A- Neuromuscular blocking drugs (NMBDs):
1- Depolarizing NMBDs-
Succinylcholine (1 1.5 mg/Kg IV)
2- Non Depolarizing NMBDs-
Vecuronium (0.25 mg/Kg IV)
Cis-atracurium (0.2 mg/Kg IV)
All patients requiring airway management
are probably at risk for aspiration of gastric
contents (Sellick maneuver).
Drugs
B- Sedative-hypnotics:
Sodium Thiopental
Propofol
C- Benzodiazepines:
Midazolam (0.5 1 mg IV)
Diazepam (2 mg IV)
D- Opioids:
Morphine, Fentanyl, Remifentanil
Drugs

E- Beta-adrenergic blocking drugs:


Esmolol (10 20 mg IV)
F- Local anesthetics agents:
Lidocaine ( 1 1.5 mg/Kg IV or
aerosol anesthetic sprays)
G- Nerve blocks
IV Drugs for Endotracheal Intubation
CONDITION HYPNOSIS MUSCLE ANALGESIA AMNESIA
RELAXAN

GCS=3 None None None None

Cardiac None None None None


arrest

Shock None SCh Fentanyl None


SBP<80mmHg
1.5mg/kg 0.5-1g/kg
Hypotension Thiopental SCh Fentanyl Midazolam
SBP 0.3-1mg/kg
1.5mg/kg 1-2g/kg 1-2mg
80-100mmHg
Head injury Thiopental SCh Fentanyl Midazolam
GCS 4-9 2-5mg/kg
1.5mg/kg 1-2g/kg 1-2mg
Combative Thiopental SCh Fentanyl Midazolam
Normal BP 2-5mg/kg
1.5mg/kg 1-2g/kg 1-2mg
Sellicks maneuver
Then

Ask for
Ventilator
Thank You

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