Pre-hospital and ER Management of Difficult Airway In
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Transcript of Pre-hospital and ER Management of Difficult Airway In
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Pre-hospital and ER
Management of DicultAirway in Trauma Patientพญ!"#$%&'() *+ญ%,#./+"
#พ0+120ญ3
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Airway Decision Scheme
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*+#45#'(678*#&)9suction: ;< : laryngoscope: =MA : surgical >needlecricothyroidotomy ? protect @-pine ? PreoBygenate
Co "+6+#2077*FG4%,H10#I7H63 DeJnitiKe airway > urgical
airway LesDicult
#.46G,+N41G,0+(2%O3+(+*0#I7H63 2 =EM;CEasy
2"3373O(0+(2%!1(2(+ Q cricoid pressure 7SO+63O(40I7 UnsuccessfulพG%+#&+78*#&)4"#G6 V =MA: =TA:WEXY awaZe intu[ation
พ(+(+62 DeJnitiKe airway> urgical airway
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Encountered Dicult
Airway algorithm
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*+#พ(+(+62"3373O(0+(2%S#$ \N]#*640O
20^+ [ag masZ Kentilation V XM_Y
*#&'' ` 9 "+6+#3O(0+(2%+N0,+*+*77*FG4%,H1 *#&'' `< 9 H63"+6+#3O(0+(2%+N0,+*+*77*FG4%, H1
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*#&'' ` 9 "+6+#3O(0+(2%+N0,+*+*77*FG4%,H1
($N"+6+##7H1 ,$ `,SI7($Nพ76'4O+
*+#2"3373O(0+(2%S#$ \N' `"7N [est looZ: 4' (̀,,G1 [lade:2 alternatiKe intu[ationtechnibues +H63
"+̂4#%
203O(0+(2%3+, XM_ %,*O3+%.1'
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+H63"+̂4#% *+#2"3373O(0+(2%S#$ \N' "̀+6
5+6]พ()' `6'#."*+#&) : alternatiKe intu[ationtechnibues
+H63"+̂4#%
*+#2"3373O(0+(2%H63#.""+̂4#%"+6S#$ \N Vfailedintu[ationY
20*$6+2 XM_ 0#I7 EWD
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*#&'' `< 9 H63"+6+#3O(0+(2%+N0,+*+*77*FG4%,H1
4,/+O.4#3N13O,' `#7H63 H1
/+O. ailed ;Bygenation V at j ]62 XM_ Y 2,#.0O3+N#745#'(6+̂ cricothyrotomy "+6+#7N2"3 EWD 7(3+N#O14#O"$*S#$ \N
+H63"+̂4#% +7N2"3 EWD ]OH63#.""+̂4#% SO##'+̂ cricothyrotomy204#O' "̀81
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+"+6+#%$1*+#4#I `7N*+#0+(2%H14#'(#7(
*#&'' 4̀+"3 k"618]. k3O(H1#$77*FG4%,7(3+N4พ'(Nพ7SO##'+̂ deJnitiKe care
].4#G 6̀*+#1k]0$N%+**+#2"3373O(0+(2%537H
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4,I \70+ Y Airway
- #+7+*+#]"1N7N7+*+#0+(2%781*$ \,
- $ญ0++N41G,0+(2%' `พ2, k3 O(78$5G4058,G153+N
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4,I \70+ Y Airway Management - @hin-=ift ManeuKer - aw-
Thrust ManeuKer- ;ropharyngeal Airway -Casopharyngeal Airway
- =aryngeal masZ Airway - Wum
Elastic Xougie- DeJnitiKe airway
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4,I \70+Y Dicult intu[ation - =EM;C
- Airway Decision cheme - Technibue for rapid
sebuence intu[ation V RY - urgical Airway
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Airway
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7+*+#]"1N7N7+*+#0+(2%781*$ \,
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7+*+#]"1N7N7+*+#0+(2%781
*$ \, Y =ooZ /+O.*#."$*#."3+(0#I7Fq6
/+O.GO0,$N!1(4พ+.#G4O#G6'+*].44,"'4'(O/+O.0+(2%!1(2*+64,I \73O(
0+(2% > 0+(2%*#.]* /+O.0+(2%4#O
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7+*+#]"1N7N7+*+#0+(2%781*$ \,
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7+*+#]"1N7N7+*+#0+(2%781*$ \,
0+* k3O("+6+#พk157S^++6
]พ() ].0+(2%H11'
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$ญ0++N41G,0+(2%' พ̀ 2, k3 O(78$5G4058
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Maxillofacial Trauma
Trauma to the midface การหกหรอมการเล อนท บรเว
!a"o#har$!% หรอ oro#har$!% มเลอ&ออก ' มการเ( ม)* +น)อ,-าร.&หล,
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Maxillofacial Trauma
/racture of ma!di01e 23าหกท บรเว 0o!$ fracture ท +,-อ,&3าน
อา4ม5าว6-78เ-9ร6บบการ.วบ.:มการหา9;4 ว9อา4มอาการ)อ,ทา,เ&นหา9;4อ:&ก +น
หรอ?ม>-ามาร2นอนราบ?&3 บ>,ว>าน>า46มทา,เ&นหา9;4
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Neck Trauma
Penetrating inury 7+%!1,4",4I71#G4O&S7 SI76'
*+#781*$ \,+N41G,0+(2%
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Neck Trauma
Xlunt inury 7+%+̂20 H1#$+14%' ̀#G4O&
larynB 0#I7 trachea 9 6'+N41G,0+(2%781*$ \,
9 6'4I7177*#G4O&tracheo[ronchial tree
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Neck Trauma
*+#1k]1+,+N41G,0+(2% 2"3373O(0+(2%
fails
surgical airway
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Laryngeal Trauma
Clinical signs ' ̀3N7*O3+7+%6'$ญ0+537*+#+14%7Nlarynx
1) Hoarseness
2) Subcutaneous emphysema
3) alpable fracture
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Laryngeal Trauma
/+O.,' \57N#.6$1#.O$N4#I `7N airwayo[struction
*+#+14%#G4O&,' \6$*4*G1#3O6*$*+#+14%#G4O&0717+0+# : ugular Kein: carotid artery *#&'5#O%#3+N*+(H636$
`,2% @T
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Ventilation
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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7
2 H
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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7
Y=ooZ %$N0O.*+#0+(2%H63"6^ `+4"67
*+#(+(5$O7N#ON7*H6343+*$, 0+(2%5I \,0#I707q* 2*+64,I \73O(0+(2% 43,*+#
(*H03 67N40,#7( 840,I7 H0+#+ '*%6k*+,
2 H
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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7
Y=ooZ k3 O(6$*,$ `N5$O5#N4N(0,+q \,
,7,#+H63 H1 +N#+(0+(2%!1(6'*+#"$!(*#.0O3+N*+64,I \70,+7N*$
#ON7* 0+(2%4vI7*0#I70+(2%พ.N+
2 H
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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7
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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7
Y *+#2 pulse oBimeter4พI `71k oBygen saturation
]. peripheral perfusion ]536G H11k Kentilation
2 H 3
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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7
Y eel 5#O%1k trachea shift
5#O%0+/+O. 9 *#.1k*F' `!S#N0$*
9 su[cutaneousemphysema
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$ญ0+*+##.+(7+*+x
V_entilationY' พ̀2, k3O(78$5G4058
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!ib "racture
O14O+0+(2%
0+(2%4#O].5I \,
/+O.+177*FG4%,2,4I71
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#ntracranial #n$ury
#k]*+#0+(2%' `G1#*5G
*+#]*4' (̀,*+FG1*5G
/+O.+177*FG4%,2,4I71
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%er&ical Spinal %or' #n$ury
($N7+%"+6+#0+(2%!1(2*+64,I \7
*#.$N6
/+O.+177*FG4%,2,4I71
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@omplete @erKical @ord
Transection *+#+14%' 5̀$13+,#G4O& phrenicnerKesV @ ]. @Y
0+(2%!1(2*+64,I \70,+7N
57N3O(0+(2%
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Airway Maintenancetechniques
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Chin-lift Maneuver
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aw-thrustManeuKer
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Orophayngeal Airway
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(rophayngeal ir*ay
+ 4I7*2 2, k3O(' 0̀61"5G ' `H636' gag reflex 0#I7 cough reflex+ SO+6(+O' 4̀06+."6tip corner of mouth
flange angle of mandile
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itfall
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!asopharyngeal Airway
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!asopharyngeal Airway
+ 4I7*2 2, conscious "semiconscious
+ ,+14",3+,xk,()*+N ,+1,G \O*7(7N k3O(
+ SO+6(+O +(%6k* - 5G Ǹ0k
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#itfall
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,xtraglottic 'e&ice -,./)
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,xtraglottic 'e&ice -,./)
4#'(*7'*I `7O3+ supraglottic deKices *+#+̂N+,SI73O(207+*+x3+,
+N1+,,7*7NKocal cord 7%+̂*$1SI7H63SO#246I `76'/+O.' `*37204*G1*+#781*$ \,' ̀#G4O&1+,3+N7N Kocal cord
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,xtraglottic 'e&ice -,./)
H1]*3 =aryngeal masZ airway:@om[itu[e : =aryngeal Tu[e Airway 4#+,+̂6+2*#&' failed intu[ation
20*$6+20,+*+*77*FG4%,0#I7
พG%+#&+3O(0+(2%!1(2 EWD 0$N278*#&),' \57NพG%+#&+^+deJnitiKe airway 4"67
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$aryngeal Mas% Airway
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&he 'sophageal-&racheal
Comitue ( '&C)
http://images.google.co.th/imgres?imgurl=http://belkmk.narod.ru/ems/combitube/Cbt1.jpg&imgrefurl=http://belkmk.narod.ru/ems/combitube/link1.htm&usg=__IrcAnvnzNuJqr_EgteUleMkAfm8=&h=726&w=663&sz=58&hl=th&start=34&um=1&tbnid=64Jdp_sLBDRIGM:&tbnh=141&tbnw=129&prev=/images%3Fq%3Dcombitube%26ndsp%3D20%26hl%3Dth%26sa%3DN%26start%3D20%26um%3D1
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http://images.google.co.th/imgres?imgurl=http://belkmk.narod.ru/ems/combitube/Cbt1.jpg&imgrefurl=http://belkmk.narod.ru/ems/combitube/link1.htm&usg=__IrcAnvnzNuJqr_EgteUleMkAfm8=&h=726&w=663&sz=58&hl=th&start=34&um=1&tbnid=64Jdp_sLBDRIGM:&tbnh=141&tbnw=129&prev=/images%3Fq%3Dcombitube%26ndsp%3D20%26hl%3Dth%26sa%3DN%26start%3D20%26um%3D1
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$aryngeal &ue Airway
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lternati&e #ntubation Techni0ues
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lternati&e #ntubation Techni0ues
*+#พ(+(+62"3373O(0+(2%0+(S#$ \N 4,*+#4พG 6̀!7*+"4*G1*+#+14%' `#.+N41G,0+(2% ? 5+66+7+%
+̂203O(0+(2%+̂+* /+(0$N%+**+#' 4̀#+2"3373O(0+(2% !1(2OGz'*+# {[est looZ| ($NH63
"+6+#2"3373O(0+(2%H12,0,q `N0#I7"7NS#$ \N 20,+̂OGz' alternatiKe intu[ationtechnibues 6+2
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LM "astrach
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Light*an' - egTrachlight)
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_ideolaryngoscopy
V egWlidescopeY
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Definitive Airway
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Definitive Airway
1 (rotracheal tube
2 Nasotracheal tube3 Surgical air*ay
cricothroi'otomy
tracheostomy
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Manual in line staili*ation
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Surgical Cricothyroidotomy
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73N' \ 2,*+#2"3
deJnitiKe airway
73N'\2,*+#2"3 definitive
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7N 2,*+#2" definitiveairway
k3O( apnea
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ขอบงช ในการใช
}@losed head inury ' ̀VWlasgow@oma score ~Y
• H63"+6+#6' oBygenation H14พ'(Nพ71O( face masZ
€€€€ #.O$N7+%4*G17$,5#+(537cerKical spine €€€€
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=EM;C Assessmentfor Dicult ntu[ation
L,M(N assesment for
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L,M(N assesment for
'ifficult intubation
L,M(N
L look externally
, e&aluate the 332 rule
M mallampati
( obstruction
N neck mobility
L L k t ll
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L Look externally
+ 1k$*&./+(,7*O3++N41G,
0+(2%].*+#3O(0+(2%#*5G0#I7H63
, , l t th 3 3 2 l
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, ,&aluate the 332 rule
• #.(.03+N#.0O3+Nincisor SO#6+**O3+
Jnger [reaths V"+6+#4G1+*H1 Y• #.(.03+N#.0O3+N hyoid [one qN chin SO#6+**O3+ Jnger [reaths
•#.(.03+N#.0O3+N thyroid notch qN ‚oorof mouth SO#6+**O3+ < Jnger [reaths
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Mallampati ir*ay %lassification
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Mallampati ir*ay %lassification
%lass 1 soft palate4 u&ula4 fauces4 pillars
%lass 2 soft palate4 u&ula4 fauces &isible
%lass 3 soft palate 4base of u&ula &isible
%lass 5har' palate only &isible
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(b t ti
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(bstruction
+ 6'/+O.' 7̀+%+̂20+N41G,
0+(2%781*$ \,H1Fq `N7+%+̂20 2"3 laryngoscopy ? *+# Kentilation+̂H1(+*
• 43,/+O. epiglottitis: trauma
N k M bilit
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Neck Mobility
+ !1(*+#20 k3O(*60,+S+NG17*0#I7]0N,0,+q \,67NพI \,+ 4,"G Ǹ' `#.46G,H1N3+(' "̀81
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Rapid ebuencenduction
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ขนตอนการทา
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ข นตอนการทา
45#'(678*#&)"+̂0#$̂+ surgicalairway 20พ#76
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ellicZ maneuKer
ขนตอนการทา
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ข นตอนการทา
• 20 succinylcholine -< mg>Zgƒ 0$N%+*(+0(37,*+64,I \777*
„zG … 20 2"3373O(0+(2%~ Xlow cu† ].$N711kS3+ @;< 37(6I7%+**+#*1 cricoid
pressure3O(0+(2% k3O(
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@omponents ;f {XET =;;‡|=aryngoscopy
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Sniffing #osition
Sniffing #osition
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Sniffing #osition
*+#*67N7537#.0O3+N cerKicalspine ]. thoracic spine ? *+#4N(' `7 atlantoocipital 20 k3O(,7,0N+(0,8,+0#I7067,"kN ƒ- 4F,5G465#25+(7(
2,3+,' \+̂20 ],O7N oral caKity:pharynB: larynB 5#N*$,^+2067N40,+N4+ glottis H1
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XURP ManeuKer
XURP ManeuKer
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XURP ManeuKer •SI7 technibue 2,*+#+̂laryngealmanipulation 4พI `73O(2040, Kocal cord1'q \,
X XacZward U Upward RP RightwardPressure
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$aryngoscope +lade
$aryngoscope +lade
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$aryngoscope +lade
Xlade ,G15#N V MillerY 9 O+N+( [lade 25537]3,
epiglottis9 ,G(62 2,41*4*
$aryngoscope +lade
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$aryngoscope +lade
Xlade ,G1!SN V MacintoshY9 O+N+( [lade #G4O&
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